
Class. 
Book J 
Copyrights? 

COPYRIGHT DEPOSIT. 



TREATISE 



ox 



ORTHOPEDIC SURGERY 



BY 

EDAYARD H. BRADFORD. M.D. 

Surgeon to the Boston Children's Hospital : Consulting Surgeon to the Boston City 
Hospital ; Professor of Orthopedic Surgery. Harvard Medical School 



AND 



EOBEET AY. LOYETT. M.D. 

Surgeon to the Infants' Hospital and to the Peabody Home for Crippled Children: 

Assistant Surgeon to the Boston Children's Hospital: Assistant in 

Orthopedic Surgery, Harvard Medical School 



THIRD EDITION 

ILLUSTRATED BY FIVE HUNDRED AND 
NINETY-TWO ENGRAVINGS 



N E W YORK 
WILLIAM WOOD AXD COMPANY 

MDCCCCV 



LIBRARY ot GONGRtSS 
fwu Copies rieteivtu 

jun 19 iwi> 

Go^ngm entry 
CLASS ^ AXC No. 

/t c /3io2? 

COPY B. 



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Copyright, 1905, 
By WILLIAM WOOD AND COMPANY 



7 



TO 

Cbarles William Eliot 

PRESIDENT OF HARVARD UNIVERSITY, THIS BOOK 

IS DEDICATED. AN EXPRESSION OF RESPECT FOR 

THE MOST STIMULATING OF EDUCATORS. 



PREFACE TO THE THIRD EDITION. 



In preparing the third edition of this work it has been necessary to 
rewrite entirely several portions, to make extensive alterations in others, 
and to rearrange chapters and subjects. These changes have been 
made in the endeavor to offer to the reader a description of the present 
condition of orthopedic surgery with its notable progress since the pub- 
lication of the second edition in 1899. 

The most marked difference between the second and third editions 
will be found in the chapters treating of congenital dislocation of the 
hip, of scoliosis, of traumatic and non-traumatic coxa vara, and of non- 
tuberculous diseases of the joints, as it is in the study of these subjects 
that the greatest advances have been made. Many original illustra- 
tions have been added and many of the old ones have been improved, 
making them more illustrative of the subjects mentioned in the text. 

A chapter giving the details of orthopedic apparatus, with descrip- 
tions and drawings of appliances found to be of practical efficiency, is 
added in the hope of giving to the general practitioner technical infor- 
mation which is of use in the treatment of orthopedic affections. 

The authors are greatly indebted to friends and colleagues for many 
helpful suggestions and for their ready permission to make use of their 
illustrations and clinical material. 

Boston, April 1st, 1905. 



CONTENTS 



CHAPTER I. 

PAGE 

Tuberculous Disease of the Joints, i 

CHAPTER II. 

Tuberculous Disease of the Spine, 16 

CHAPTER III. 
Tuberculous Disease of the Hip, .84 

CHAPTER IV. 

Tuberculous Disease of the Knee, .147 

CHAPTER V. 

Tuberculous Disease of the Ankle and other Joints, . .171 

CHAPTER VI. 

Infectious Osteomyelitis — Infectious Synovitis and Arthritis, . 186 

CHAPTER VII. 

Arthritis Deformans, 196 

CHAPTER VIII. 

Other Affections of the Bones and Joints, . . . . 224 

CHAPTER IX. 
Rickets, Knock-knee, and Bow-legs, ...... 271 

CHAPTER X. 

Coxa Vara and Coxa Valga, . . . . . .. -308 

CHAPTER XL 

Lateral Curvature of the Spine, . . . . . -322 

v 



vi CONTENTS. 

CHAPTER XII. 

Other Deformities of the Spine and Thorax, 



375 



CHAPTER XIII. 

Torticollis, . . . . . . . . . . 392 

CHAPTER XIV. 

Anterior Poliomyelitis, ._-'.. . . ... . . . . 406 

CHAPTER XV. 

Spastic and other Paralyses, . . . . ' . . . . 445 

CHAPTER XVI. 
Functional Affections of the Joints, . . . 467 

CHAPTER XVII. 

Unilateral Atrophy and Hypertrophy, . .- . • 470 

CHAPTER XVIII. 
Congenital Dislocations, ....... . 479 

CHAPTER XIX. 
Talipes, • . . 518 

CHAPTER XX. 

Flat-Foot and Other Deformities of the Foot, . . -559 

CHAPTER XXI. 

Practical Details of Apparatus, 601 



ORTHOPEDIC SURGERY. 

CHAPTER I. 
TUBERCULOUS DISEASE OF THE JOINTS. 

Pathology. — Etiology. — Prognosis. — Principles of Treatment. 

Orthopedic surgery deals with the prevention and correction of 
deformity, and demands not only a study of the deformities of the hu- 
man body, but also some knowledge of the affections which produce 
them. Of these the most important are the tuberculous diseases of 
the joints. 

Bone tuberculosis has been called strumous, scrofulous, and fungus 
disease, caries of bone, etc., and various theories as to the predisposing 
cause have been presented. It is known to be the result of the inva- 
sion of the tubercle bacillus, which frequently finds a favorable soil for 
development in the spongy bone of the growing epiphyses. 

PATHOLOGY. 

Articular tuberculosis begins as an affection of the spongy tissue of 
the epiphysis, generally near its line of junction with the shaft, occa- 
sionally near the articular cartilage. It occurs usually as a localized 
disease, appearing in one or more distinct foci ; a simultaneous tuber- 
culous infiltration of the whole epiphysis, however, rarely happens. 

The common form of tuberculous infection of the epiphysis is the 
one spoken of as focal or encysted, when the first change is the forma- 
tion of single or multiple foci of tuberculous degeneration. On section 
of the diseased epiphysis the first noticeable change consists in a local 
hyperemia of some part of the spongy tissue. There then appears in 
this hyperaemic area a small, grayish, translucent spot, almost as small 
as one can see, which grows more gray and increases in size, while a 
zone of hyperaemic tissue develops around it and the neighboring bone 
looks boggy from an excess of the transuded fluid. At first usually 
there is no synovitis ; it is purely a localized ostitis. 

The tubercle bacilli, being lodged in the marrow of the bone, cause 
a multiplication of the surrounding cells, probably by the action of a 
toxin, and a typical tubercle is formed. Such an area consists of a cen- 
tral mass of giant and epithelioid cells surrounded by a zone of lym- 



ORTHOPEDIC SURGERY. 



phoid cells. As the tuberculous area increases by multiplication of 
the cells, the centre degenerates, forming a necrotic mass in which fat 
drops may be seen. Sometimes the tubercle bacillus can be found, 
usually in small numbers, in the giant cells, or in the epithelioid cells, 
or between them. The process extends by the formation of other tu- 
bercles, apparently due 
to the multiplication of 
the tubercle bacilli and 
their diffusion through 
the tissues. New ne- 
crotic areas like the 
first are found, which 
coalesce and form a 
mass of caseous mater- 
ial. Around the tuber- 
culous area there 
appears a zone of non- 
tuberculous granulation 
tissue early in the proc- 
ess. During the later 
and reparative stages of 
the process this area 
becomes less vascular 
and is converted into 
denser fibrous tissue. 

As the individual 
tubercles meet and co- 
alesce, they form, in the 
marrow of the bone, ir- 
regular caseous masses. 
In this way large areas 
of bone may be involved 
by peripheral enlarge- 
ment of the tuberculous 
area. This area may 
soften and a tubercu- 
lous bone abscess may 
result, the purulent ma- 
terial containing bone 
fragments like sand. 
Instead of forming a " bone abscess " the process may result in the 
formation of a sequestrum composed of necrotic trabecular retaining 
their shape and lying in a cavity in the bone. About the sequestrum 
is a layer of granulation tissue. The sequestrum may take the shape 








m 



A* 



fill 
o 






vv ^:i:r 



^ 



*enc 



Fig, 



-Section of Tuberculous Synovial Membrane. 
(Nichols.) 



TUBERCULOUS DISEASE OF THE JOINTS. 



3 



of a wedge having its base toward the joint, in which case it is known 
as a " bone infarct." 

As the diseased focus grows larger it looks more yellow in spots, 
and shows at its centre a tendency to cheesy 
degeneration, and later in the history of the 
affection one finds nodules, varying in size 
from that of a pea to a hazelnut, which are 
filled with a putty-like substance, such as the 
cheesy material found elsewhere in the body, 
except that it contains spicules of bone from 
the trabecular, and in the larger foci pieces of 
dead bone of considerable size are found. 

Later in the history of the affection the 
tuberculous nodule may break down into 
purulent material. 

Generally the original focus is sur- 
rounded by smaller tubercles, which aid in 
its extension; but the chief work is done 
by the erosive action of the granulations, 
which take the place of the progressively 
rarefied bone. 

From the stage of tuberculous infiltration the process may follow 
any one of three courses : the diseased focus may be absorbed and so 




Fig 



Tumor Albus. Small focus 
in upper epiphyseal line of tibia. 
Synovitis of joint, but no tuber- 
culous process apart from focus 
as noted. Death from miliary tu- 
berculosis, a, Epiphysis; &, pri- 
mary focus; c, shaft. (Nichols.) 



^ 



*$S 



* -"% 



NJ I 




Fig. 3. — Tuberculous Epiphysis. Vertical section through the head of the radius, a, Shaft of 
radius ; b, epiphyseal cartilage ; c, epiphysis ; d, joint surface ; cartilage ; e, tuberculous 
primary focus; /", perforation of joint cartilage and infection of joint; g; tuberculous 
"pannus" extending over joint cartilage. (Nichols.) 



cured ; it may extend to the periphery of the bone and break through 
the periosteum and empty itself there ; or, lastly and probably most 
commonly, it may extend to the joint and infect that. 



ORTHOPEDIC SURGERY. 




mrn<®^-- »■. M& mm 



1. The absorption of the diseased focus is theoretically possible up 
to a late stage in the process, so long as the disease remains strictly 
local and no sequestra of any size have formed; the pus may become 
cheesy and calcified. 

2. The next most favorable termination to the disease is when the 
focus does not infect the joint, but breaks through the periosteum and 
discharges into the periarticular structure. This happens when the 

focus is so situated that 
the line of least resist- 
ance takes it to another 
part of the bony surface 
away from the joint, 
there forming probably 
an abscess which must 
be evacuated externally 
or break. Sometimes 
this ends the disease; 
the granulation tissue be- 
comes fibrous, and then 
osseous, and the disease 
is over. This, according 
to Krause, is most likely 
when the focus is in the 
upper or lower end of the 
tibia or in the olecranon. 1 
It is not likely to occur 
in the hip on account of 
the extensive distribu- 
tion of the capsule. 

3. Probably the com- 
monest course for this 
localized ostitis to pursue 
is to break into the joint 
cavity, and the ease with 
which infection of the 
joint from the epiphysis 
is produced will be 
readily understood by considering the pathological conditions. 

The seat of the disease in the beginning is ordinarily not far from 
the cartilage. At first it excites no joint inflammation, but when it 
reaches a certain stage, even before it breaks into the joint, inflamma- 
tory reaction in the joint begins. 2 The inflammation of the joint at 

1 Krause : " Tub. der K. und Gelenke," 1891. 

2 Lannelongue : " Coxo-tuberculose," Paris, 1886. 







Fig. 4. — Section of Tuberculous Synovial Membrane. 
Numerous tubercles with giant cells. Between these, 
oedematous granulation tissue with many lymphoid 
and plasma cells. (Nichols.) 



TUBERCULOUS DISEASE OF THE JOINTS. 5 

first is non-tuberculous, the synovial membrane appearing thick and 
cedematous, the cavity of the joint being filled with a serous inflamma- 
tory exudate. This process may be very extensive. 

Perforation of the joint by the tuberculous focus is the next step in 
the process. When the tuberculous focus underlies it, the cartilage of 
the joint begins to disintegrate and appears softened and yellow, and 





k 



\ 



U- 



y 



Fig. 5.— Tuberculous Knee, Process of Repair Advanced. Small focus persists, a, Tibia ; 
b, tuberculous softening ; c, femur ; d, patella. (Nichols.) 

finally breaks through. The perforation frequently occurs near liga- 
ments. The tubercle bacilli, having entered the joint, are quickly dis- 
seminated by movement of the articulation, and the synovial membrane 
becomes infected. 

The synovial membrane then appears thick, smooth, and shining, 
and sometimes nodular ; the surface is studded with small specks not 
larger than the head of a pin. The yellow tuberculous areas increase 
and soften, and tuberculous ulcers of the synovial membrane form. 
The thickened synovial membrane extends as a pannus growth over the 



6 ORTHOPEDIC SURGERY. 

edge of the articular cartilage, sometimes covering the whole cartilage. 
At the same time the tuberculous process may extend between the car- 
tilage and bone. The cartilage beneath the pannus layer is destroyed 
and disintegrated, while the free surface of the cartilage becomes fibril- 
lated and ulcers appear in it also. When the tuberculous process ex- 
tends beneath the cartilage the latter is eroded and destroyed. 

Large areas of cartilage may be detached from the underlying bone, 
and sometimes the entire cartilage may be loosened, as in the hip-joint. 
Under these conditions the denuded end of the bone is seen to be cov- 
ered with nodular granulation tissue filled with tubercles, caseous and 
otherwise. As the disease goes on the cartilage is destroyed or cast off 
in flakes, and the denuded bones are attacked by the tuberculous proc- 
ess and are eroded. As a result of this, articular cavities are enlarged 
and distorted, and distortions and subluxations may occur. The tonic 
muscular contraction accompanying joint disease tends in certain joints 
to crowd together the softened ends of the bones and hasten the wear- 
ing away. 

Microscopical examination of the diseased area at any time before 
all structure is lost shows a typical granulating tuberculosis. 

Thickening of the capsule, infiltration of the periarticular tissues, 
and thickening of the ends of the bones are clinical manifestations, and 
abscess formation and all the other complications are ready to follow. 

About the affected joint is formed a layer of granulation tissue 
which may be converted into fibrous tissue. This process may be very 
extensive and accounts for such phenomena as the ovoid swelling in tu- 
mor albus and the thickening of the trochanter in hip disease. This 
fibrous tissue may be cedematous, and the spaces may contain a fluid 
reacting to stains like mucin. 

Repair is brought about by the formation of fibrous tissue, probably 
arising from the layer of non-tuberculous granulation tissue which 
grows into and replaces the tuberculous material. Caseous material is 
largely absorbed, and the inspissated remainder is replaced by fibrous 
tissue or is calcified and encapsulated. Fibrous, cartilaginous, or bony 
ankylosis may result from the process of repair. 

It is most important to note that the process of repair may be in- 
complete, and that small areas of tuberculous material encapsulated by 
fibrous tissue may persist for a long time and under favorable condi- 
tions may become active and cause a recurrence of the disease. This 
fact must always be borne in mind in forcibly manipulating convales- 
cent tuberculous joints. Or the repair may be complete and the previ- 
ously inflamed tissue be converted into cicatricial bone — usually more 
firm than the original structure. 

Certain variations of this process must be described as other types 
of synovial affection from that described are found at times. 



TUBERCULOUS DISEASE OF THE JOINTS. 7 

Arborescent tuberculous synovitis is the name given to a condition 
in which the synovial membrane is covered with branching arborescent 
tags frequently coated with fibrin. Sometimes a large amount of fatty 
tissue may be present, constituting the " lipoma arborescens." 

Solitary tuberculous nodules of the synovial membrane are described. 
Nodular and even polypoid growths with little tendency to caseation 




FlG. 6.— True Ankylosis of the Hip Joint. (Joachimsthal.) 



project into the joint. Although at first the rest of the synovial mem- 
brane is but little affected, it becomes involved later. 

Hydrops articulorum tuberculosus was a name given by Konig to a 
chronic effusion of joints said to be primarily synovial. In these there 
is said to be at first no marked thickening of the synovial membrane. 
Later the membrane assumes the typical character of tuberculous syn- 
ovial inflammation. A similar condition of joints with a purulent effu- 
sion is described as "empyema tuberculosum." 

It has always been asserted by writers on bone tuberculosis that 
primary disease of the synovial membrane occurred. Volkmann, how- 



8 ORTHOPEDIC SURGERY. 

ever, as early as the writing of his classical monograph, said : " The 
fungous inflammations of the joints begin generally, and in children 
almost without exception, not at all as an arthropathy, but as a pure 
osteopathy, with a very circumscribed caseous or tuberculous ostitis." ' 

Nichols, 2 in one hundred and twenty tuberculous joints examined 
from children and adults, many from excisions, a considerable number 
from autopsies or amputations, did not see a joint in which, if all the 
bones entering into the joint were sawed open, one or more old bone 
foci were not found. Complete examination of a joint at operation is 
usually difficult and oftenest impossible, so that conclusions as to the 
absence of primary bone disease based upon such examinations must 
be accepted with caution. 

Although primary tuberculosis of the synovial membrane is de- 
scribed by those whose statements carry great weight, the results of 
Nichols' investigations must be borne in mind, which are positive and 
not negative conclusions. And it may be assumed for clinical purposes, 
until the contrary is proved, that practically all tuberculous joint dis- 
ease has its origin in bone. 

Cold Abscesses of Joints. — If the tuberculous process in the bone 
reaches the surrounding tissues by perforation of the cortex and peri- 
osteum or by rupture of the joint capsule, an abscess is likely to occur. 
The area of tuberculous softening in the periarticular tissues is formed 
by the coalescence and caseation of tubercles. Surrounding the soft- 
ened area is a layer of tuberculous tissue, about which is another layer 
of cedematous and vascular granulation tissue. This process may ex- 
tend until a large cavity has been formed. 

The contents of these abscesses are composed of caseous material 
from the degeneration of the tubercles and exuded serum with necrotic 
pieces of bone. In the fluid are polymorphonuclear leucocytes, often 
taking up little or no stain on cover slips. Pyogenic organisms are ab- 
sent unless present by secondary infection. The fluid maybe like true 
pus ; it may be so thick that it will hardly flow ; it may be thin and 
watery and contain coagula, or it may be red or brownish from hemor- 
rhage. 

Microscopically tubercle bacilli may be found in the abscess, but 
they are to be identified, even after prolonged search, in only about 
one-third of the cases. In such cases inoculation experiments must be 
relied upon to establish their presence. 

The wall of these abscess cavities is composed of an inner layer of 
tuberculous tissue, outside of which is a layer of secondary inflamma- 
tory tissue. The inner layer may be granular or necrotic and ulcerated. 
The abscess extends by peripheral enlargement in the line of least re- 

1 Volkmann : Klin. Vortr., v., p. 1405. 
-Nichols: Orth. Trans., vol. xi., p. 383. 



TUBERCULOUS DISEASE OF THE JOINTS. 9 

sistance. The walls of tuberculous sinuses consist of an inner layer of 
tuberculous tissue, outside of which is a zone of cedematous granulation 
tissue. 

Tubercle bacilli in the tissues are frequently found, though not in- 
variably, as in the process of decalcification necessary to cut sections of 
bone for microscopic examination they may become so disorganized as 
to stain with difficulty or not to stain at all. 

Inoculation of animals with tissue from bones and joints affected by 
this type of disease produces general tuberculosis, 1 and the disease may 
be experimentally produced in animals. 2 

General miliary tuberculosis of bone occurs in connection with gen- 
eral miliary tuberculosis. The marrow is studded with miliary tuber- 
cles; necrosis and inflammatory reaction are slight or are absent. 3 

ETIOLOGY. 

Heredity. — That heredity is a factor in causing tuberculous joint 
disease has long been claimed. Whether the tuberculous virus can be 
directly transmitted as such from father or mother to the offspring 
must still be held open to question/ but that the surroundings of cer- 
tain families weaken the resistance and favor tuberculous invasion ap- 
pears not improbable. 

Figures which attempt to show what proportion of children with 
joint disease inherit a tendency to these diseases are notoriously un- 
trustworthy. In the class of hospital patients from whom most of 
these statistics come, anything approaching accurate information with 
regard to the diseases of which relatives have died cannot be expected. 
There is also an inclination on the part of parents to deny the existence 
of tuberculous disease in their parents and relatives. In this way pa- 
rents of all classes are much more anxious to establish some traumatic 
cause for the affection of the joint than to have it supposed that the 
child inherited any constitutional taint. Again, it must be remembered 
that in a community in which approximately ten per cent of all deaths 
are from phthisis, phthisis must necessarily appear m the family histo- 
ries of a certain proportion of any group of individuals whose antece- 
dents are inquired into. For these reasons the statistics cannot be 

1 Cheyne : British Med. Jour., April. 1891. 

'-Deutsch. Zeit. f. Ch.. 1872. xi., 317.— Schiiller: "Exp. und histol. Unter- 
suchungen." Stuttgart. 1SS0. — Cent. f. Ch.. 1SS6. No. 14. 

:; Konig : Archiv f. klin. Chir.. 26, p. 822.— Caumont : Deutsch. Zeit. f. Chir., 
xx.. 137. — Krause : Deutsch. Chir.. Lief. 28a. — Deutsch. med. Woch., 1SS6. 9-13.— 
Cent. f. Chir.. 1SS7. p. 52.— Quoted by Barber: Brit. Med. Jour.. June 23d. 1888.— 
Pfeiffer: Fort, der Med.. 1888. No. 1, p. 33.— For further detail the reader is re- 
ferred to the article of Nichols (Trans, Am. Orth. Assn.. vol. xi.), which has been 
freely used by the writers. 

4 Cheyne : " Tuberculous Disease of Joints." p. 97. 



io ORTHOPEDIC SURGERY. 

regarded as other than inaccurate, and only approximating the truth, 
but the error is likely to lie always on one side, in making the propor- 
tion of inheritance too small. 1 

Traumatism. — Experimentally it has been shown that trauma to the 
joint of a tuberculous' animal may cause tuberculous joint disease, but 
that it does not do so in the healthy animal. It has been established 
that contusions and wrenches cause the effusion of blood in the spongy 
tissue of the bone. Cases are seen in which tubercles develop directly 
from the clot, just as in a syphilitic individual a gumma may develop 
at the site of an injury to the bone. " There are cases in which the 
swelling from the fall merges into the tuberculous swelling." 2 It would 
therefore seem rational to assume that trauma caused tuberculous joint 
disease in children who inherited a constitutional taint. But it becomes 
evident at once that this is not all, for every surgeon of experience 
must have in his mind cases in which joint disease of a tuberculous 
type has followed injury in children whose family histories were excep- 
tionally good. 

From one-sixth to one-half of all cases would appear from the col- 
lected statistics to be traumatic. 

In certain cases traumatism alone must be accepted as the causative 
factor, while in some cases no cause can be assigned. 

The exanthemata must be mentioned as being the cause of tubercu- 
lous joint disease in a certain proportion of cases, probably a larger 
proportion than has been suspected. Measles and scarlet fever are the 
most common eruptive diseases to be followed by these sequelae. 
There are very few figures bearing upon the subject. The effect of 
the exanthemata in causing other forms of joint disease will be alluded 
to later. 

The entrance of the bacilli is apparently most often through the 
respiratory and digestive tracts. 

It is probable that whatever continuously diminishes the power of 
resistance and of repair in growing children increases what may be 
termed the vulnerability of the epiphyses, and furnishes the soil for the 
development of tubercle bacilli and the consequent results. 

Age. — Tuberculous joint disease is pre-eminently a disease of child- 
hood. It is not congenital, and under one year it is not common. 
The majority of cases occur between three and ten years of age. 3 

1 Gibney : " Strumous Element in Joint Disease," N. Y. Med. Jour., July, 1877. 
^-From preface of German translation of " The Mechanical Treatment of Pott's 
Disease."— Croft: Clin. Soc. Transactions, London, vol. xiii. — Nichols: Orth. 
Trans., xi., p. 358. 

' 2 Konig : Deutsch. Zeit. fur Chir., 1879, xi. 

3 N. M. Shaffer: "Am. Clin. Lectures," vol. Hi., 141; Sonnenberg: Arch. f. 
klin. Chir., 1881, xxvi., 789; Lannelongue : Loc. cit.— " Hip Disease in Child- 
hood," p. 2. — L. A. Sayre : " Orthopedic Surgery and Diseases of Joints." 



TUBERCULOUS DISEASE OE THE JOINTS. II 

The liability of the aged to tuberculous joint disease must not be 
overlooked. 1 The patients may be seventy-five or ninety, and cases of 
hip disease present the same pathological appearances here as in 
young children. The course of the disease is more rapid and destruc- 
tive than in the young, and its etiological relations are decidedly more 
obscure. 

The reasons why tuberculous joint disease affects children to so 
great an extent are as follows : 

In the active period of growth more change is going on and there- 
fore more instability exists and consequently greater liability to disease. 
Children are more liable to falls and injuries, which are such a fertile 
source of joint and bone lesions. It is not till after puberty that the 
process of natural selection has eliminated the weaklings from the 
stock. Children are kept quiet less easily than adults, and a slight in- 
jury may develop into a formidable disease. Tuberculosis in general 
is common in childhood. 

Sex is not a factor of any prominence, but there is a slightly larger 
proportion of tuberculous joint disease among boys than among girls.' 2 

Distribution of Chronic Tuberculous Joint Disease. — The relative 
frequency with which tuberculosis attacks the various joints in children 
may be estimated from the following figures : 

At the Children's Hospital, from 1869 to 1903 inclusive, 5,950 cases 
of tuberculosis of the joints were distributed as follows: spine, 2,867; 
hip, 2,281; knee, 375; ankle, 394; elbow, 33. These practically all 
occurred in children under the age of twelve. 

In 211 cases of joint tuberculosis among the out-patients occurring 
in children under two years, there were 120 cases of Pott's disease, 61 
of hip disease, and 29 of tuberculosis of the knee-joint. 3 

Judson has called attention to the great preponderance of joint dis- 
ease in the lower extremity as contrasted with the upper limb. Ana- 
lyzing the reports of two orthopedic institutions in New York City, he 
found that in a single year the following number of cases of disease of 
the different joints were treated: 

Hip-joint disease 577 

Knee-joint disease 181 

Shoulder disease 6 

Elbow disease 8 

or 758 patients had disease of the joints of the lower extremity, while 
in the same time there appeared only 14 cases of joint disease in the 
upper extremity. 

In joint disease, when one or more articulations are involved, any 

*" Clinical Lectures and Essays. Senile Scrofula," 2d ed., p. 345. 
-Gibney: Loc. cit., p. 206. 
3 Thorndike: Orth. Trans., ix., p. 196. 



12 ORTHOPEDIC SURGERY. 

combination may be found ; but the most common are hip disease and 
Pott's disease, knee disease and Pott's disease, and double hip disease. 
Disease of the knee- and hip-joint at the same time is not common, and 
double tumor albus is unusual. 

DIAGNOSIS. 

The recognition of tuberculous joint disease is to be based upon cer- 
tain general phenomena modified by the anatomical conditions of the 
joint affected. These diagnostic signs are considered in connection 
with the individual joints. 

The use of tuberculin as a means of diagnosis is open to the criti- 
cism that its results are attended with so much uncertainty that its 
value in the individual case is always open to question and cannot be 
assumed to be a reliable demonstration that tuberculosis is either pres- 
ent or absent in that case. 1 It has been demonstrated that in a certain 
per cent of well-marked cases of pulmonary or other tuberculosis, tu- 
berculin gives a negative result, while in other cases, presumably non- 
tuberculous, a certain percentage of positive results is obtained. The 
great frequency of tuberculous invasion has been shown by the autop- 
sies of Babes, 2 for example, who found lesions of the bronchial glands 
in more than one-half of his autopsies on children ; and those of Nae- 
geli, 3 who found, in 508 consecutive autopsies, that 97 to 98 per cent 
showed evidences of tuberculosis. Under these circumstances tuber- 
culin must necessarily be unreliable in demonstrating joint tubercu- 
losis. 4 

The inoculation of material from suspected joints into guinea-pigs 
forms a reliable means in the diagnosis of tuberculosis of the joints. 

The x-ray is an aid in the diagnosis of joint tuberculosis where the 
process is sufficiently advanced to have caused the absorption of lime 
salts in the affected area or to have destroyed any part of the bony 
structure. In early cases the radiograph may be normal when disease 
is present. 

PROGNOSIS. 

The destructive process which is so prominent a feature of joint 
tuberculosis is almost from the first accompanied by a reparative proc- 
ess tending to limit the destruction, protect the surrounding tissues, 
and prevent generalization. The prognosis depends in the individual 

1 F. W. White : Boston Med. and Surg. Journal, August 5th, 1898 (with bibli- 
ography). — Schliiter : Deutsch. med.Woch., 1904, viii.,30, p. 272 (with literature). 
Brit. Med. Journ., 1903, vol. ii., pp. 48, 96. 

2 Babes, quoted by Burrell : " Surg. Tub. ," Trans. Mass. Med. Soc. , xix. , 1903. 
3 Naegeli: Arch, fur path. Anat., vol. clx. 

4 " Indirect Tuberculin Reaction." Bull, de lTnstitut Pasteur, t. ii., April 30,. 
1904, P- 333- 



TUBERCULOUS DISEASE OF THE JOINTS. 13 

case upon which of these two processes prevails over the other. The 
former is favored by inefficient local treatment, bad inheritance, poor 
general condition, unfavorable surroundings, and, in general, what may 
be termed poor resistance to the tuberculous process. The reparative 
process is favored by the reverse of these conditions. In the majority 
of all cases of joint tuberculosis, properly treated at a fairly early stage, 
the outlook is favorable. The prognosis is more favorable in children 
than in adults. 

TREATMENT. 

Since bone tuberculosis has been shown to be one manifestation of 
tuberculous infection and not the result of an unknown evil, the prin- 
ciples of treatment are more clear. 

Resistance to the infection by the tubercle bacillus is furnished 
when the individual is in a normal state. The antidotes to be relied 
upon to check its advance after it has found lodgment are not only good 
air and food, but such general activity as will promote normal metabol- 
ism. Tuberculosis is prevalent and fatal among caged animals — a fact 
which is to be borne in mind in the treatment of bone tuberculosis. 

The treatment is both general and local. The general treatment 
consists in giving the patient the best possible environment and in fur- 
nishing such conditions that normal activity will cause the least possi- 
ble injury to the part locally affected. 

In tuberculosis of the lung the patient is in constant danger of self- 
infection or increase of the process from the inhalation of infected 
material. In bone tuberculosis no such danger exists. Strong, well 
ossified bone does not offer suitable soil for the bacillus. Bone tissues 
when invaded resist the advance of tuberculous infection by surround- 
ing the diseased area with a thick enveloping mass of tissue and by 
subsequently repairing the invaded region by the development of strong 
bone. Traumatism, which injures this bone construction and furnishes 
undeveloped cells instead of firm bony structure, favors the spread of 
the tuberculous process. 

The treatment of bone tuberculosis, therefore, consists in promoting 
such general conditions as will favor repair (general treatment) and the 
protection of the parts from injury during the disease (local treatment). 

General Treatment. — The patient should be placed in the most fa- 
vorable environment available in the matter of food, home surround- 
ings, air, sunlight, proper clothing, exercise, avoidance of fatigue, and 
similar requirements. 

Outdoor Treatment. — Of these requirements outdoor air is of 
the utmost importance, and the open-air treatment of surgical tubercu- 
losis ' is nowhere more beneficial than in joint disease. The outdoor 

1 Burrell : Comm. Mass. Med. Soc, 1903, xix., 11, p. 303. 



14 ORTHOPEDIC SURGERY. 

method recognized as of such value 1 in the treatment of pulmonary 
tuberculosis is advisable. 2 During the day the patient should be out 
of doors or in a room with one or more windows open. In winter 
proper protection against cold should be obtained by warm clothes 
rather than by heated rooms. Such patients should sleep out of doors 
in tents or well-aired sheds. During the summer this offers little diffi- 
culty, and in the winter such treatment is available even in a New 
England climate. From Christmas, 1903, through the winter, the pa- 
tients at the Convalescent Home of the Children's Hospital at Welles- 
ley, with Pott's disease and hip disease, lived and slept in an unheated 
shed with skylights or doors open. Properly protected by woollen caps 
and heavy blankets, they suffered no discomfort, and the beneficial 
effect on the local process was evident. 

The importance of the treatment by fresh air and sunlight has been 
recognized in Europe in the establishment of seaside sanatoriums for 
children with tuberculous joint disease. It is being recognized in 
America that a convalescent home in the country is an almost neces- 
sary part of a surgical hospital for children. 

Drugs. — The writers are of the opinion that drugs, except tonics 
when required, are of little or no value in the treatment of joint tuber- 
culosis. 

Local Treatment. — Fixation, distraction, and protection, along with 
operative treatment, are considered in speaking of the individual joints. 
Other local measures are occasionally of use, in addition. 

Biers congestive treatment 3 depends upon hyperemia as a thera- 
peutic agent, and in connection with proper mechanical treatment it 
may be of benefit in the knee, ankle, elbow, or wrist. A congestion 
of the affected joint is induced by bandaging above and below the 
joint with cotton webbing or rubber bandages and allowing the con- 
gestion to continue for an hour daily. The congested parts should feel 
warmer than the normal skin, but the process should never be pushed 
to the degree of causing pain. 

X-ray treatment consists in an exposure of the affected joint to the 
^■-rays for a certain period every day or every second day. In a fairly 
large number of cases of joint tuberculosis under mechanical treatment 
treated in this way in addition, checked by cases under similar condi- 
tions not so treated, the writers have not been able to detect any bene- 
fit from the use of the .r-ray. 

Counter-in itation, inunction, ignipunctnre, and similar measures 

1 Med. Record, November 18th, 1902, p. 736. Am. Med., March 21st, 1903, 
440. Munch, med. Woch., 1902, xlix., 108 1. 

-Zeitsch. f. Tub. und Heilstatt., July, 1902, pp. 366 and 369. 

3 Frieberg : Am. Journ. Orth. Surg., August, 1904, ii., 150. — Luxembourg: 
Munch, med. Woch., 1904, 10. 



TUBERCULOUS DISEASE OE THE JOINTS. 15 

have fallen into more or less disuse since the better appreciation of the 
pathology of joint tuberculosis and the essentials of its treatment. 

Massage, manipulation, hot-air baths, douches, and similar measures 
to stimulate the local circulation are to be avoided during the acute 
stage of the process as essentially undesirable. In late convalescence 
they may prove of much value. 



CHAPTER II. 
TUBERCULOUS DISEASE OF THE SPINE. 

Definition. — History. — Pathology. — Occurrence and Etiology. — Symptoms. — 
Complications. — Diagnosis. — Differential Diagnosis. — Prognosis. — Treat- 
ment. 

Definition. — Pott's disease is the name applied to a destructive path- 
ological process which attacks the bodies of the vertebrae. The other 
names by which the affection is known are as follows : Spondylitis, 
Malum Pottii, Caries of the spine, Kyphosis, Angular curvature, Tu- 
berculosis of the vertebrae, and Spinal curvature. In German it is 
known as Die Potfsche Kyp/iose, Spitzbuckel, Wiukelformige Knickitng 
der Wirbelsaule, and Tubejritlose Wirbelentzwidung ; in French as 
Cyphose, Mai de Pott, and Mai Vertebral. 

History. — Antero-posterior curvature of the spine is an affection 
which was described by the ancients, and was known to Hippocrates 
and Galen, who attributed its cause to tubercle " within and without the 
lungs." Ambroise Pare wrote of it and used a metal cuirass in its 
treatment, but it was not until the time of Percival Pott, in 1779, that 
any accurate description of the disease was given. 1 In honor of that 
surgeon the disease is chiefly known by his name. The existence of 
the disease in prehistoric times in North America is proved by a speci- 
men in the Peabody Museum, Cambridge, Mass. 

PATHOLOGY. 

Pott's disease represents the result of a destructive ostitis affecting 
the spongy tissue of one or more of the vertebral bodies. This ostitis 
is tuberculous in type and follows the same course as tuberculous 
ostitis occurring at the epiphyses of the long bones, as in hip disease, 
tumor albus, etc. 

The first appearance noticeable to the naked eye on examining a 
section of a diseased vertebra at an early stage of the disease is a small 
hyperaemic spot in some part of the spongy portion of the body of the 
vertebra, generally near the anterior surface of the body. This spot 
grows larger and more red as the process extends, and finally the cen- 
tre becomes opaque and grayish, while a zone of hyperaemia surrounds 

! Pott: "Remarks on that Kind of Palsy Affecting the Lower Limbs," etc., 
London, 1779. 

16 



TUBERCULOUS DISEASE OF THE SPINE. 



17 



it. A focus of tuberculous ostitis is present. If this process extends, 
the opaque spot becomes larger, and finally cheesy degeneration of its 
centre takes place. At other times both caseation and degeneration 
into tuberculous pus take place, and a localized abscess of bone exists, 
probably encapsulated in a membrane of inflammatory tissue, which sur- 
rounds the focus, endeavoring to protect the surrounding healthy bone 




Fig. 



7. — Pott's Disease Involving the whole Dorsal Region. 
(Peabody Museum, Spec. 17,223. 



Prehistoric Indian remains. 



from the erosive action of the focus. Microscopical examination shows 
a mass of tubercles in a rarefied spongy bone tissue, and in the tuber- 
cles are to be found tubercle bacilli. 

The focus of tuberculous material may either be absorbed or calci- 
fied, or, as happens much more commonly, the ostitis may increase 
until it has destroyed a large part or the whole of a vertebral body. In 
its course of enlargement it may include portions of bone, the nutrition 
of which is cut off by the adjacent inflammatory destruction. Such 
portions necessarily become necrosed, and with caseous matter, granu- 
lation tissue, and the products of inflammation constitute an area of 
altered and degenerated structure in the vertebral body. If this dis- 
eased area has become large enough, the vertebral body gradually be- 
comes incapable of sustaining as much pressure as before. From the 



8 



ORTHOPEDIC SURGERY. 



peculiar weight-bearing function of the vertebral column, the pressure 
upon each vertebral body is always considerable when the vertebral col- 
umn is in the erect position. If one vertebral body is becoming exca- 
vated, a point will be reached where it can no longer sustain the weight, 
but must give way slowly or suddenly. A forward tilt of the whole 
vertebral column above the seat of disease is then inevitable, with a 
certain amount of backward angular deformity at the diseased vertebra. 
This is the mechanism of the production of the knuckle in the back. 




FIG. 8. — Lower Dorsal Region. One 
intervertebral disc destroyed. Ex- 
tension of process backward to dura 
and formed along prevertebral liga- 
ments. Moderate knuckle hardened 
in upright position, so that gravity- 
pressed diseased vertebrae together. 
a, Tuberculous softening. (Nichols.) 



b'~' 




FlG. 9. — Lower Dorsal Region. Opposite half of 
specimen rested on knuckle while hardening, 
so that gravity extended the spine. Marked 
separation of diseased vertebras, a. Tuberculous 
disease beneath prevertebral ligaments; b, cav- 
ity between diseased vertebras. (Nichols.) 



It is, in brief, a softening and crushing of one or more vertebral bodies 
and a giving way of the column at that point as a necessary mechanical 
result. 

This process is limited, as a rule, to the vertebral bodies ; the trans- 
verse, articular, or spinous processes are rarely affected secondarily or 
primarily, their structure of hard bone apparently protecting them from 
tuberculous invasion. 

The intervertebral cartilage between the diseased vertebrae becomes 
fibrillated and disintegrated and disappears. 

There may be two or more foci in one vertebra, or the whole body 
may be equally affected ; the disease may be limited to one spot, forming 



TUBERCULOUS DISEASE OF THE SPINE. 19 

a localized abscess of the bone, or it may extend so as to involve the 
adjacent vertebrae. If the disease remains limited to the centre of the 
vertebra, but little deformity may result. Primary disease of two ver- 
tebral bodies in different, non-adjacent parts of the spine is rare. But 
an extensive destruction of two or more adjacent vertebrae from pri- 
mary disease of one may be said to be the rule in Pott's disease. In 
some instances this destructive process may be limited to the surfaces 
of a large number of vertebral bodies ; in others a few contiguous ver- 




FlG. 10. — Spine, Lower Dorsal and Lumbar Region. Extreme knuckle. Lower ribs rest on 
pelvis. Change in angle of ribs due to continued deformity. Calibre of spinal canal not 
diminished, a, Knuckle. (Nichols.) 

tebral bodies are completely destroyed. The number of vertebrae in- 
volved necessarily varies ; in some instances the bodies of twelve or 
even more have been destroyed, producing a deformity which involves 
almost the whole of the spinal column. A superficial ostitis of the an- 
terior surfaces of the bodies, without involving the intervertebral carti- 
lages or impairing the weight-bearing function of the vertebrae, occurs, 
but is rare. 

Abscess. — " In a considerable portion of cases of tuberculous disease 
of the spine no abscess is recognized during life, but in cases seen at 
autopsy an abscess is almost invariably found, although it may be of 
small size. The tuberculous material early pushes up the prevei tebral 
ligaments and forms a flattened, soon a nodular swelling in front or 
sometimes to one side of the vertebrae. The contents of such a swell- 
ing are like the contents of other tuberculous abscesses " (Nichols). 1 

1 Nichols : Orth. Trans., vol. xi., p. 391. 



20 



ORTHOPEDIC SURGERY. 



In certain cases the formation of tuberculous pus is a characteristic 
of the disease from the first, and in these cases abscesses are apt to be 

a conspicuous feature. The tu- 
berculous pus finds its way, dur- 
ing or after the destruction of 
the body of the vertebra, into the 
surrounding tissues and gravi- 
tates downward. It appears usu- 
ally in the course of the sheath 
of the psoas muscle when the 
disease is situated in the lower 
half of the spine, but the site of 
the abscess necessarily depends 
upon the place of the original 
disease, and may be in the mouth 
— as in retropharyngeal abscess 
— in the neck, in the axilla, or 
in the back, lungs, abdomen, or 
groin. The contents of such ab- 
scess as a rule contain no pyo- 
genic bacteria. 

Paralysis. — In certain cases 
meningitis and myelitis are pres- 
ent in the cord opposite the seat 
of disease, accompanied some- 
times by what is virtually the 
destruction of the cord at that 
point. The paralysis is very 
rarely caused by direct pressure 
of bone, as it is uncommon for 
even very marked deformities of 
the spine to narrow the spinal 
canal to any great extent. More- 
over, paralysis sometimes occurs 
before there is any deformity, 
and it often recovers while the 
deformity gets worse. Many 
cases with extreme deformity are 
never paralyzed at all. In 52 
cases collected from literature by 
Schmaus l in which autopsy af- 
forded a chance of determining 
the cause of the paralysis, compression was mentioned as a cause 
1 Schmaus : " Die Compression-Myelitis der Caries," etc., Wiesbaden, 1890. 



a- 




FlG. 11.— Lower Lumbar Reg-ion. Section ob- 
liquely through lumbar vertebrae and ilium in 
the line of the ilio-psoas muscle. Small tuber- 
culous area in lowest lumbar vertebra. In 
pelvis is large tuberculous abscess in sheath of 
ilio-psoas muscle, a, Tuberculous focus in 
lumbar vertebrae ; 6', peritoneum and sheath of 
ilio-psoas: c, abscess; d, ilium. (Nichols.) 



TUBERCULOUS DISEASE OF THE SPINE. 



21 



in only 39 cases; in 33 of these a caseous pachymeningitis was 
noted. In 6 bony pressure existed, and in 5 of these the odontoid 
process of the axis was dislocated. In only 1 was kyphotic displace- 
ment the cause of the pressure. Kraske J estimates bony pressure 
as the cause in two per cent of the cases. Autopsy shows that in 
cases of paralysis the ^process ordinarily begins as an external pachy- 
meningitis. Compression from thickened meninges must therefore 
be classed as one cause of paralysis. This meningitis is generally 
clearly tuberculous in character. Myelitis or, better, meningomyelitis, 




x-. * 








Fig. 



-Sagittal Section of the Spine from the 9th Dorsal to the 2nd Lumbar. Compression 
of cord and abscess. (Schulthess.) 



however, at times exists from an early stage in the cord itself. This is 
not to be demonstrated as tuberculous by the microscope. This menin- 
gomyelitis is followed, if it is severe enough, by ascending and de- 
scending degenerations in the columns of the cord. CEdema also is 
present, at first apparently non-inflammatory in character, but later 
inflammatory. This also must be a factor in producing symptoms, and 
alone explains the immediate improvement in certain cases after forci- 
ble rectification of the deformity. Thrombosis and embolism of spinal 
vessels must be accounted as possible factors in contributing to the 
1 Kraske : Archiv f. klin. Chir., vol. Ixi. 



22 



ORTHOPEDIC SURGERY. 



disturbance in the cord. The order of changes is as follows: oedema, 
diffuse softening, and sclerosis. If the myelitis ceases, it leaves a cer- 
tain amount of sclerosis of the cord at the seat of the disease. This, 
again, may be very slight, or the cord may be reduced to a fraction of 
its former size, and yet serve well enough to transmit healthy nervous 
impulses. 

There may be a direct strangulation of the cord by the vertebral 
arches, obliterating the canal ; or an abscess from diseased bone may be 




Fig. 13.— Tuberculosis of Lower Dorsal 
Region. Large area of tuberculous soft- 
ening involving two vertebras. Inter- 
vertebral disc destroyed. Process ex- 
tends forward beneath prevertebral 
ligaments and pushes aorta forward. 
Process also extends backward to dura. 
a, Beginning abscess ; b, aorta ; c,. tuber- 
culous softening of vertebras. (Nichols.) 




FIG. 14.— Lower Dorsal and Upper 
Lumbar Vertebras. Tuberculous 
softening in anterior portion of 
bodies of five vertebras. Marked 
knuckle. Portion of one vertebra 
pushed backward into spinal ca- 
nal, but does not produce pressure 
upon spinal cord, a, Tuberculous 
disease of vertebra ; b, tubercu- 
lous foci ; c, cord ; d, fragments of 
bone projecting into spinal canal. 
(Nichols.) 



a source of pressure within the canal. A caseous deposit from the 
vertebrae and a loose piece of bone have been found as sources of 
pressure. 

In proportion to the extent of the disease and the number of verte- 
brae involved, an angular deformity of the spine may be present to any 
extent. In severe cases this angular deformity leads to many second- 
ary pathological changes. The shape and capacity of the chest are 
necessarily very much altered, and the ribs sometimes sink into the 
pelvis. As a result of these changes in chest capacity, hypertrophy of 
the heart, often accompanied by valvular disease, is common. The 
aorta may be distorted as a result of the deformity. Thomas Dwight 
reports a case in which its course " might be compared to an S lying 
on its' side, with the ends bent strongly back to fit around the promi- 



TUBERCULOUS DISEASE OE THE SPINE. 



23 



nence of the spine."' ! Lannelongue ' 2 found a very marked narrowing 
of the calibre of the aorta in many cases. Sometimes it was reduced 
even to a mere slit. 

A cure, however, is possible even in cases with very advanced de- 
formity. This cure can come about in 
one of two ways: (1) By ankylosis be- 
tween the surfaces of the bodies of 
the diseased vertebrae — a very slow 
process, which requires years for its 
completion ; (2) by the deposit of bone 
in the inflammatory material, thrown 
out around the column by the action 
of the formative ostitis which accom- 
panies the destructive process, the 
vertebral column being supported, as 
it were, in surrounding bone. 




Fig. 15.— Lower Dorsal Region. Extensive tuber- 
culous softening- involving two vertebrae ; inter- 
vertebral disc destroyed. Knuckle very slight, 
probably because the focus was in the centres of 
the vertebral bodies, and laterally destruction 
was not complete, a, Tuberculous cavity, in- 
volving centres of bodies of two vertebras. 
(Nichols.) 




FIG. 16.— Distortion of Aorta. From 
a case of spinal caries in an adult. 
At one point marked constriction 
of the aorta. Angular deformity 
very marked, a, Constriction of 
aorta. (Dwight.) 



OCCURRENCE AND ETIOLOGY. 

Sex. — Sex does not appear to be an important factor in causing 
Pott's disease, though statistics vary somewhat. 

Age. — The disease is more common in childhood. Mohr found, in 

1 Dwight: Amer. Jour. Med. Sciences. January. 1S97. 
-Rev. de Chir., August 10th, 1886, p. 671. 



24 



ORTHOPEDIC SURGERY. 



72 cases, that the disease occurred between the first and fifth years in 
29 per cent ; between the sixth and tenth years in 22 per cent ; be- 
tween the eleventh and fifteenth years in 22 per cent ; between the 
sixteenth and twentieth years in 16 per cent; and above the twentieth 
year in 11 per cent. Drachman found in 161 cases 41 per cent be- 
tween one and five years, and 36 per cent between five and ten years. 
The oldest patient was seventy- 
seven years of age, and the youngest 
eight weeks. Gibney found that 87 
per cent were under fourteen years 

of age ; 7 per cent between fourteen V~ 13 1 WB^^^Si 

and twenty; and 4 per cent over 




Fig. 17.— Complete Absorption of 
Vertebral Body. (Warren Mu- 
seum.) 




Fig. 18.— Complete Bon}' An- 
kylosis. (Warren Museum.) 



twenty-one. Taylor found in 375 cases that 226 were under five; 68 
between five and ten; and 24 between ten and fifteen. 1 

Localization. — Any of the vertebrae may be attacked, but in varying 
frequency. As there are more dorsal vertebrae than either cervical or. 
lumbar, it is natural that the number of cases of dorsal disease should 
be greater than in the other regions. 2 Dollinger in 538 cases deter- 
mined the vertebrae originally affected to be as follows : cervical, 63 ; 
dorsal, 321; lumbar, 154. The most frequent seat was between the 
twelfth dorsal and first lumbar. The upper half of the column was 
affected primarily only 117 times. In a series of 1,355 cases from the 
Hospital for the Ruptured and Crippled, the distribution was as fol- 
lows: cervical, 100; dorsal, 854; lumbar, 317. 

Although, as is seen, the locations of relative frequency given by 
the different observers do not agree, it would appear that certain por- 



New York Med. Record, August 13th, 1881, 
Disse: " Skeletlehre," 1896. 



TUBERCULOUS DISEASE OE THE SPINE. 25 

tions of the spine are more liable to attack than certain others, and 
that the regions most liable to the disease were those which were the 
most exposed to jars or increased pressure ; and that the disease would 
be more frequent where the hinges of motion at the spinal column 
came, varying to a degree according to age and occupation, or where 
there was the greatest exposure to the effects of violent jars. 

Causation. — It may thus be assumed that the localizing cause of 
Pott's disease is jar or superincumbent pressure; the influential cause 
being that physical state which is incapable of resisting slight trauma, 
exposing the tissue probably to the invasion of the tubercle bacillus. 

Gibney, in an examination of 185 cases, found a hereditary tuber- 
culous taint in /6 per cent. In 45 per cent a weakened condition 
from previous sickness was 
found ; and in 22 per cent 
both an inherited and an 





FIG. 20.— Attitude Assumed by Children with 
Fig. 19.— Attitude in Cervical Caries Acute Pott's Disease, and in Other Cases 

of only Moderate Severity. Necessitated by Psoas Contraction. 

acquired diathesis were found. Taylor, in 845 cases, found 53 per 
cent with a history of preceding trauma (Vulpius, in 810 cases, found 
the same percentage [53]); in 15 percent there was disease of the 
lungs in nearer or more distant relatives; in 19 per cent so-called scrof- 
ula was asserted ; and in 34 per cent a sickly condition. Vulpius found 
a history of hereditary tuberculosis in 16 per cent of his 810 cases. 

SYMPTOMS. 

Few affections have a clinical history which varies so widely and 
appears under such different guises as that of Pott's disease. The one 



26 



ORTHOPEDIC SURGERY. 



constant symptom, however, which accompanies all cases of Pott's dis- 
ease and must often form the chief reliance in diagnosis is muscular 

rigidity at the affected portion of the 
spine. Just as spasm of the joint 
muscles is the constant symptom of 
chronic joint disease, so is restricted 
motion between the diseased verte- 
brae the constant accompaniment of 
Pott's disease, in its early or later 
stages. 

Typical cases of Pott's disease 
are so characteristic in their symp- 
toms that the diagnosis is evident 
almost at a glance. The guarded 
character of all the movements is 
perhaps the most striking feature. 
In walking, in stooping, or in lying 
down, the spine is most carefully 




Fig. 



-Attitude in Severe Pott's Disease 
with Psoas Contraction. 



guarded against 



jar and against mo- 



tion, attitudes are assumed which re- 
lieve the vertebral column of some of the weight of the body, and a glance 
at the naked child shows unnatural modes of standing and walking. 

A prominence of the 
vertebrae is ordinarily pres- 
ent as early as at this 
stage, and of tener than not 
pain is acute and aggra- 
vated by motion. Consti- 
tutional disturbance is also 
very likely to be present 
when the disease has been 
of even a few weeks' dura- 
tion. Loss of flesh and 
appetite and inability to 
go about much without 
fatigue are often among 
the first symptoms to at- 
tract attention. 

Peculiarity of attitude 
and gait, muscular stiff- 
ness, and referred pain are 
the most prominent of 
the earlier symptoms, and 
they may be present be- fig 




n Cervical Pott's Disease. 



TUBERCULOUS DISEASE OF THE SPINE. 



27 



fore a projection has been noticed. The importance of recognizing 
these early symptoms can hardly be overstated, as it is on an early 
recognition of the affection that the hope of a ready cure is to be based. 
Attitude. — The peculiarity in attitude noticed early in the disease is 
due either to reflex muscular spasm— similar to that seen in joint dis- 
ease—or to an unconscious effort on the part of the patient to prevent 
jar or any increased pressure upon the affected vertebral bodies. 
These attitudes necessarily vary according to the point of the spine at- 





FlG. 



-Lordosis in Lumbar Pott's FlG. 24. 
Disease. 



-Deformity in Dorsal Pott's Disease Show- 
ing Spasm of Muscles. 



tacked. In disease of the upper cervical region, the most common atti- 
tude is that of wry -neck. 

When the disease is in the lower cervical or upper dorsal region, the 
chin is held somewhat raised, to balance the weight of the head on the 
articular facets, suggesting the position of a seal's head when out of 
water. The spinal column below the point of disease is abnormally 
straight, and in some instances curved slightly forward, while in the 
lower dorsal region an exaggerated backward projection of the spinous 
processes may be seen; this projection, due to a compensating curve, 



ORTHOPEDIC SURGERY. 



is sometimes so marked as to suggest that the disease has attacked 
another part of the spine. 

In the middle dorsal region the attitude to be noticed most fre- 
quently is an elevation of the shoulders. Temporarily a slight lateral 
deviation of the spine is to be seen. 

In the lumbar region, the patients in the early stage frequently will 
be noticed to lean backward, like pregnant women or adults with large 
abdomens. A peculiar position and characteristic sidling gait, which is 
sometimes seen at a comparatively early stage of disease in the lower 
dorsal or lumbar region, is due to a slight contraction of the psoas and 
iliacus muscles. 

In a late stage, when psoas abscess is present, a marked contraction 
of these muscles takes place ; but even when there is no evidence of 




—Acute Pott's Disease ; Supporting Body by Arm: 



existence of suppuration or of a psoas abscess, slight inflammatory irri- 
tation of the muscles will produce a limitation to the arc of extension 
of the thigh on the trunk. 

In general, in addition to the square position of the shoulders, the 
peculiar position of the head, and the erect attitude of the upper part 
of the spine, which prevents the superincumbent weight of the trunk 
and upper extremities (above the diseased portion of the spine) from 
falling forward upon the diseased vertebral body, the gait is peculiar; 
the patient walks more on the toes than on the heels, and with the 
knees slightly bent — in such a way that all possible springs may be 
brought into play to diminish the jarring of the spine. 



TUBERCULOUS DISEASE OE THE SPIKE. 



29 



These peculiarities of attitude and position vary in severity according 
to the acuteness of the disease ; they may be at one time more notice- 
able than at another. Characteristic also at this stage of the disease 
is a muscular stiffness, which becomes more marked after the patient 
has been quiet for a while (during sleep). The stiffness of the 
limbs diminishes or disappears after the patient has moved about. A 
certain amount of muscular rigidity of the muscles of the back will be 
felt on palpation in affections of the middle dorsal and lumbar regions; 
stooping which involves arching of the back forward is difficult or im- 
possible in disease of the lower spine, and in attempting to stoop in 





Fig. 



-Severe Grade of Psoas Con- 
traction. 



FlG. 27.— Lateral Deviation of Spine 
from Dorsal Pott's Disease. 



order to pick up any article from the floor the patient will keep the 
spine erect and reach the floor, lowering himself with an erect trunk. 
by bending the knees. 

It will often be noticed that children become tired more easily than 
usual, and after playing about for a time will desire to lie down, to rest 
their arms upon a chair or seat, or to support the head with their hands, 
or the trunk by holding on to the thighs, according to the part of the 
spine affected. 

The amount of muscular stiffness, rigidity, and difficulty in main- 



30 



ORTHOPEDIC SURGERY. 



taining the spine erect is in a measure an index of the degree of activ- 
ity of the disease. In early cases the muscles on either side of the area 
of the affected vertebrae will often, on bending the back, be seen to 
spring out in relief, acting like physiological splints to the diseased ver- 
tebral column. 

Various modifications of characteristic attitudes are at times pro- 
duced. The most common of these probably is the flexion of the thigh 
which results from psoas contrac- 
tion, usually the result of psoas 
abscess. The contraction of the 
muscle is both the warning and the 
accompaniment of the abscess. It 
may be present to such a degree 
that the leg cannot be put to the 
ground in walking and the use of a 
crutch is necessitated. 





Fig. 28.— Lateral Deviation of Spine in 
Dorsal Pott's Disease. Back view. 



Fig. 29.— Lateral Deviation of Spine in 
Lumbar Pott's Disease. 



Lateral deviation of the spine is an attitude to be found in Pott's 
disease and is discussed in its relation to lateral curvature under the 
head of diagnosis. As a rule, the lateral curve of Pott's disease is char- 
acterized by very slight, if any, rotation of the spinal column on a ver- 
tical axis. 1 

The lateral deviation has no especial significance except in indicat- 
1 Annals of Surgery, July, 1889. 



TUBERCULOUS DISEASE OF THE SPINE. 3 1 

ing a certain modification of treatment to be considered later. It is 
most severe in acute cases. The divergence may reach 8° from the 
perpendicular at its maximum point, 1 and in thirty cases measured by 
the writers did not exceed this; 5 makes a divergence enough in 
amount to make the fitting of apparatus difficult. This divergence is 
diminished by the recumbent position. It is sometimes the first symp- 
tom of Pott's disease, and one which has attracted but little attention. 

Pain. — In certain cases of Pott's disease pain is absent altogether, 
but it is often present to a most distressing degree, and it forms a more 
prominent symptom than it does in hip disease or tumor albus, for in- 
stance. In a measure it tends to mislead both parents and physician, 
for the pain is rarely complained of in the back, but is referred to the 
peripheral ends of the nerves, and is thus described as being felt in the 
abdomen, chest, or limbs. Chipault has described a class of cases in 
which severe pain in the kyphus is present, and has given to the con- 
dition the name " apophysalgie Pottique." 2 Abdominal pain passes for 




Fig. 30. — Case of Neglected Pott's Disease with Psoas Contraction and Severe Deformity. 

"stomach-ache," and pains in the limbs for "growing pain" or rheu- 
matism. In general, it may be said here that persistent localized pain 
in the case of a child is a symptom demanding very great attention. 

The sleep of these children is apt to be much disturbed by pain, for 
the suffering from Pott's disease, like all the pain of bone diseases, is 
more severe at night. In the milder cases this is manifested by simple 
restlessness, while in more severe cases it takes the form of crving 
spells. This may even be the case when the children can walk about 
without pain during the day. As a rule the pain is aggravated by ex- 
ercise, jars, and wrenches. It is not always elicited by pushing down 
on the child's head. Superficial sensitiveness over the spinous proc- 
esses is not a symptom of Pott's disease. 

The pain is usually subacute, and may be only occasional. At 
times the attack may be very severe, accompanied by intense hyperes- 
thesia, so that the pressure of the bedclothes cannot be tolerated, and 
patients in this condition have been supposed to have intense peritoni- 
tis or pleurisy. The subacute form is more common, and this, togeth- 

1 Orth. Trans., iii.. 182. '-"Trav. de Neurologie Chir.," 1898. 



32 



ORTHOPEDIC SURGERY 



er with muscular stiffness, often gives rise to a diagnosis of rheuma- 
tism, sciatica, or neuralgia. Analogous to these attacks of pain are 
disturbances of the functions of other nerves — manifested in cough, 
peculiar grunting respiration, dyspnoea with cyanosis, gastric disorders, 
obstinate and recurring vomiting, and troubles of the bladder, with or 
without pain at the end of the penis. Patients suffering in this way 
have been treated for bronchitis, 
pneumonia, gastritis, or cystitis. 
In one notable instance the op- 
eration for stone in the blacl- 





FlG. 32.— Dorsal Pott's Disease with Marked 
FIG. 31.— Result in Severe Case of Dorsal Kyphosis and Backward Projection of 

Pott's Disease. Spine. 



der — lateral cystotomy — was performed. No vesical trouble was dis- 
covered, but at the autopsy disease of the lumbar vertebrae was 
found. 

These periods of suffering may become intense — constituting acute 
attacks, subsiding after rest, and recurring at intervals without appar- 
ent exciting cause. 

Eye symptoms may exist in Pott's disease. Partial dilatation ex- 



TUBERCULOUS DISEASE OF THE SPINE. 



33 



isted in thirty-six out of thirty-eight cases reported by Bull, and neuri- 
tis and optic atrophy have been reported. 1 

It is to be expected that pain will be diminished and generally con- 
trolled by efficient mechanical treatment. Certain cases, however, are 
from the first so intractable that pain persists in spite of all that can be 
done. Fortunately such cases are not the rule, and in general it may 
be assumed, when pain comes on in the course of treatment, that the 
apparatus does not fit, if mechanical treatment is used, or that the pa- 
rents are not careful in the nursing of the child or in carrying out treat- 
ment thoroughly. In a few instances it will be found that pain cannot 
for a time be entirely checked by treatment. A sudden and violent 
increase of pain should lead one to suspect an approaching access of the 
disease — with increase of the deformity — the formation of an abscess, 
or the beginning of paralysis. In cases in which recovery from Pott's 




FlG. 33.— Method of Measurement of Deformity in Pott's Disease. Shows lead strip and card- 
board tracing. (Children's Hospital Report.) 

disease has occurred with great deformity, the lower ribs may have 
sunk below the crest of the ilium, and by rubbing against it may cause 
severe pain. 

Deformity. — The most characteristic feature of Pott's disease is the 
deformity — that is, the projection backward of one or more spinous proc- 
esses. This is occasioned by the destruction of the vertebral bodies. 
The projection is primarily of the vertebrae first affected, but following 
this other vertebrae are more or less involved, and the curve increases, 
with the establishment of secondary curves. The sharper the projec- 
tion, as a rule, the more acute is the process ; but this rule, however 
true in the upper dorsal region, has occasional exceptions in the lower 
dorsal and upper lumbar regions. It may be stated that in old cases 
there is, as a rule, more of a curve and less of an angle. It is not abso- 
lutely true that the greater the amount of the disease the greater the 
1 Knies : " Das Sehorgan und seine Erkrankungen," 1893, p. 205. 
3 



34 



ORTHOPEDIC SURGERY. 



deformity, for there may be extensive disease on the front of several 
bodies without diminishing the weight-bearing function of all of them ; 
but, generally, the more vertebrae involved the greater is the projec- 
tion. 

It is most important to keep a record of the deformity in each case 
under observation. This record is most easily taken by a simple 
method. 

A strip of sheet lead half an inch wide, of the quality known to the 
dealers as "four pounds to the foot," is made straight by pressing out 
the curves, and is laid along the spinous processes of the child, who lies 
on his face on a flat table without a pillow, with his hands at his sides 



FEB. 6 1688 



MA* 5 




JAN.I2 1879 



AUG.29 



FE BY 30.1871 




C D E 

p IG . 34 .— Tracings of the Deformity in Pott's Disease. A B, not treated ; CDF, patient did 
not continue treatment ; F G H, patient discontinued treatment. (H. L. Taylor.) 



and his head turned to one side. With the fingers the lead is pressed 
against the spinous processes, and when it is removed it is stiff enough 
to keep its shape. The curve is then drawn upon a piece of cardboard 
by means of this lead strip, placed on its side and used as a ruler. The 
cardboard curve is cut out with scissors and the concavity is then ap- 
plied to the child's back to see if it fits accurately. If not, it should be 
trimmed with the scissors until it does. The slightest change in the 
outline of the back can then be detected at any subsequent visit, be- 
cause any increase or diminution of the deformity will cause the card- 
board cutting to fit the outline of the back imperfectly. 

If the deformity is left to itself, its tendency is to increase until a 
spontaneous cure results or death ensues. In many cases in dorsal 
Pott's disease this result is reached only after an enormous deformity 
has occurred. In cervical and lumbar Pott's disease spontaneous cure 



TUBERCULOUS DISEASE OE THE SPINE. 



35 



is more likely to occur, and, when it occurs, is accompanied by much 
less deformity than in the dorsal region. 

When this spontaneous cure occurs, the change takes place gradu- 
ally and does not cause narrowing of the spinal canal. The gibbosity 
is most marked in disease of the upper dorsal region, and least in the 
lumbar region. The secondary curvatures are : in cervical Pott's dis- 
ease, a dorsal incurvation below the disease, with a slight lumbar ex- 
curvation ; in dorsal disease, 
an increased hollowing in 
above and below the gibbosi- 
ty of the disease; in lumbar 
disease, a long curvature with 
convexity inward above the 
disease. The neck becomes 
shortened and thickened in 
cervical Pott's disease; the 
trunk is shortened in disease 
of other parts of the spine ; 
there is also in cases of long- 
duration a diminution of an 
uncertain origin in the 
growth of the whole bod)-, so 
that adults recovered from 
Pott's disease of ordinary 
severity are usually of less 
than average height. In se- 
vere cases the limbs more 
usually grow nearer to the 
normal amount, and are nec- 
essarily out of proportion to 
the length of the trunk. 

Taylor l has formulated 
the retardation of growth in 
patients with Pott's disease 
as follows : 

" Disease of the cervical region is least harmful in this regard ; dis- 
ease of the dorsal, especially the lower half, the most so; while disease 
of the lumbar region occupies an intermediate position. An average 
growth of an inch to an inch and a half, extending over a number of 
years, instead of the normal two inches and upward, is fairly satisfac- 
tory for patients under treatment or soon after the active stage of the 
disease. A growth of one and one-half to two inches for a similar pe- 

1 H. L.Taylor: Transactions of the American Orthopedic Association, xi., 
p. 197. 




36 



ORTHOPEDIC SURGERY. 




/ 



I 



/ 



riod indicates that disease is arrested or is retrogressive; in other 
words, that the case is doing well. Very slow or absent growth indi- 
cates progressive disease or impaired vitality. Intercurrent disease or 
too long absence from surgical supervision is often followed by a dimi- 
nution of the growth rate." 

An alteration in the shape of the lower part of the face takes place 

in marked dorsal disease, 
with a facial expression 
which is characteristic. 

Cases in which the de- 
formity is rapidly increas- 
ing are, as a rule, charac- 
terized by much pain. 

Deformity of the chest 
is a constant accompani- 
ment of dorsal Pott's dis- 
ease. The vertebral col- 
umn cannot give way and 
form an angular deformity 
without altering the posi- 
tion of the sternum and 
ribs. The deformity is 
usually a thrusting down- 
ward and forward of the 
sternum with a lateral flat- 
tening of the chest. In 
short, it results in the for- 
mation of a pigeon-breast. 
There may, however, be a 
prominence of the ribs on 
both sides of the sternum, 
where a depression of the 
sternum is seen. Some- 
times the pigeon-breast is 
the first symptom to attract the attention of the parents, and for that 
alone the children are brought to the surgeon. 

High Temperature.— Cases with Pott's disease not infrequently have 
an elevation of the temperature in the afternoon. This temperature is 
diminished or often reduced to normal in cases under bed treatment. 
The rise of temperature is from one to three degrees in average cases 
and occurs independently of abscesses. This statement rests on ten 
hundred and fifty observations made at the surgical out-patient depart- 
ment of the Children's Hospital. 1 

1 Amer. Jour. Med. Sciences, December, 1891. 



f 



Fig. 36.— Rounded Deformity from Old Disease in the 
Dorsal Region. 



TUBERCULOUS DISEASE OE THE SPINE. 



37 




General Condition. — Pott's disease produces a more profound im- 
pression upon the general condition than do the other tuberculous joint 
and bone diseases. The 
children affected are 
frequently fretful and 
capricious, made so 
either by the disease 
and by ill-health or by 
injudicious petting on 
the part of the family. 
They are also often pre- 
cocious and their mental 
development is superior 
to that of healthy chil- 
dren of the same age. 
They are, moreover, deli- 
cate, take cold easily, and 

Seem especially liable tO Fro. 37.— Tracings from Cases of Pott's Disease Showing 

Slight attacks Of pneU- l he f ecessio » of the Deformity under Mechanical 

c> . J- .treatment. 

monia. Patients with 

Pott's disease are of course liable to attacks of tuberculous menin- 
gitis, but the experience of the writers would lead them to believe 

that the liability to this was 
less than in hip -joint dis- 
ease. Necrosis of the ribs is 
one of the more uncommon 
complications. 



COMPLICATIONS. 

Paralysis. — Partial or com- 
plete paralysis of the legs is a 
frequent complication of Pott's 
disease. It may occur in early 
or late, in mild or severe cases, 
and no apparent exciting cause 
can be assigned for its ap- 
pearance. 

The clinical picture is 
what one would expect from 
a consideration of the patho- 
logical condition; a paralysis 
of motion mild or severe, fol- 




FlG. 38.— Depression of Sternum in Dorsal Pott's 
Disease. 



38 ORTHOPEDIC SURGERY. 

lowed, if the case gets worse, by more or less paralysis of sensation. 
The motor paralysis varies from mere muscular weakness to complete 
loss of power. It begins as a sense of fatigue, a dragging of the feet ; 
then there is inability to hold one's self erect. Unless the disease is 
in the lumbar region, the reflexes are exaggerated, and muscular 
spasms may start from the least irritation; they frequently appear 
spontaneously. In severe cases the muscles are flaccid and the legs 
may be powerless. With the secondary degenerations in the cord, 
rigidity sets in. The bladder and rectum are paralyzed toward the end 
of all severe cases, and whenever the lumbar enlargement is involved ; 
in milder cases they escape. The arms are paralyzed in certain in- 
stances of dorsal Pott's disease. Of the sensory paralysis below the 
lesion there is less to be said ; it is apt to begin as paresthesia ; anaes- 
thesia afterward may come on to a greater or less extent. Trophic 
disturbances are not to be seen unless in exceptional cases. 

The wasting of the muscles and diminution of electric contractility 
are usually only such as disuse would cause. 

In a few instances affections of the joints, supposed to be second- 
ary to lesions of the cord, have been noted, and instances are men- 
tioned in which herpes zoster, apparently due to the same cause, was 
present. 

Paralysis is rarely an early symptom in Pott's disease, though it has 
been observed before the stage of deformity. The frequency of paraly- 
sis is indicated by the figures collected in 700 cases observed by Dol- 
linger. Forty-one cases of paralysis were noted (5.8 per cent). In 26 
of the 41 cases the disease involved the region from the third to the 
seventh dorsal vertebrae inclusive. 

Paralysis is usually bilateral ; it may, however, be unilateral, and in 
some unusual instances it occurs above the point of deformity. Tay- 
lor and Lovett ' found, in an examination of 59 cases of paralysis (out 
of 445 cases of Pott's disease), that the location of disease was as fol- 
lows : 1 cervical, 7 cervico-dorsal, 37 dorsal, 7 dorso-lumbar, 4 lumbar, 
3 unclassified. The deformity was large in 20, medium in 10, small in 
17 (in 12 unclassified). The paralyzed cases presented no worse de- 
formity than that seen in average cases. In 26 the outline of the de- 
formity was rounded and gradual; in 16 it was distinctly sharp. The 
paralysis occurred on the average about two years after the beginning 
of the disease. It came on immediately after a fall in 4 cases. The 
duration of the paralysis was never, in the cases reported, over three 
years, except in one case, when it persisted with but little improvement 
for six years ; in 2 cases it lasted three years ; in 5 cases it lasted two 
years. A recurrence of the paralysis was noted in 6 cases, 4 having 
two attacks and 2 having three. Out of 209 cases collected by Myers, 
1 Med. Rec, 1886, xxix., 699. 



TUBERCULOUS DISEASE OF THE SPINE. 



39 



in 105 the paralysis accompanied disease above the eighth dorsal verte- 
bra. Recurrence is not an unusual feature in its history. 

Paralysis is not a common occurrence in Pott's disease under effi- 
cient protective treatment. Its prognosis is extremely favorable in 
mild cases, or in severe ones if they can be treated early. Recovery, 
when it occurs, is generally complete, leaving no trace of the disability 
of the limbs. 

Abscess.— In most cases of Pott's disease, especially in those under 
efficient treatment, the whole course -is run without any evidence of 
suppuration, but in others abscesses forfn a distressing complication. 

The earlier treatment is begun and the more efficiently it is carried 
out, the less liable are abscesses to form ; but it must not be assumed 
that the occurrence of abscesses is evidence of incomplete treatment. 
In certain cases of severe disease an abscess cannot be avoided. 

The causes of the development of an abscess are the same in Pott's 
disease as in bone tuberculosis elsewhere. What the abscess-determin- 
ing influences are, which in some 
instances give rise to profuse suppu- 
ration and the absence of which in 
other cases allows immunity, is at 
present conjectural. They may be 
supposed to be dependent on the 
amount of constitutional or local 
power of resistance on the part of the 
patient, the extent of the bacillary 
invasion, the severity of a previous 
injury, and the individual degree of 
recuperative power or of reparative 
tissue development. If we consider 
the situation of the vertebral bod- 
ies (the point of origin of abscesses) 
— projecting into the cavities of the 

thorax and abdomen, surrounded by the lungs and intestines, close to 
the large vessels and the oesophagus — it will seem extraordinary that 
the formation of an abscess does not more frequently lead to a fatal 
termination. In fact, however, the fluid contents of the abscesses fol- 
low in the line of least resistance, and the layers of fasciae in most 
cases protect the larger cavities of the trunk from invasion ; the pus 
generally extends to the surface at points distant from its origin, ap- 
pearing in the neck, in the lumbar region, in the groin, or in Scarpa's 
triangle. 

Psoas abscess is the most common. It is very rarely met with in 
children unless in connection with vertebral disease, but in general it 
is an almost pathognomonic sign of dorsal or lumbar Pott's disease. 




.V7777//A 



Fig. 39.— Diagram of Abscess from Pott's 
Disease. 



40 



ORTHOPEDIC SURGERY. 



The abscess tends to enlarge more on its outer than on its inner 
side because the fascia is less resistant there. It finally reaches Pou- 
part's ligament and bulges in the groin. The pus may, however, 




Flu. 40. — Psoas Abscess. 

travel as far down as the insertion of the psoas muscle. There is then 
a swelling both above and below Poupart's ligament, and fluctuation 
may be detected between the two by placing one finger above the liga- 
ment and the other below it. 

Pus may find its way to the iliac fossa either from a psoas abscess 
or directly from the diseased bodies. At times a collection of pus will 




Psoas Abscess. 



through 



the sacro-sciatic foramen 



work over the crest of the ilium or 
and point in the gluteal region. 

Abscesses may accumulate in the inguinal region above Poupart's 
ligament, simulating hernia. Before passing down the sheath of the 



TUBERCULOUS DISEASE OF THE SPINE. 



41 



psoas muscle, they may enlarge in the abdominal cavity beneath the 
peritoneum, constituting a layer of subperitoneal abscesses. In time 
these abscesses descend down the thigh, but they may remain for a 
long time large, threatening, abdominal tumors. 

A lumbar abscess is the outcome of disease of the lumbar vertebrae. 
It appears as a swelling in the loin on 
one side or the other just outside the 
quadratus lumborum. At times it is 
associated with dorsal disease and not 
with lumbar. 

Abscess in dorsal disease may pass 
between the ribs and appear as a tumor 
on one side of the spine, or the accu- 
mulation of pus may remain in the 
posterior mediastinum, giving rise to 
cough and dyspnoea, and may be de- 
tected as an area on one side of the 
spine, dull to percussion. 

Cavical abscess appears as a tumor 
at the side of the neck, simulating the 
ordinary deep cervical abscess, or it 
may appear as a bunch at the back 
of the pharynx, causing difficulty in 
breathing and swallowing. The latter 
is known as a retropJiaryngeal abscess. 

Abscesses, however, may burst into 
the mouth, trachea, bronchi, medias- 
tinum, oesophagus, or pleura. They 
may rupture into the intestines, blad- 
der, vagina, rectum, or the abdominal 
cavity; and one case is reported in 
which a spinal abscess simulated a fis- 
tula in ano. Abscesses may also burst 
into the spinal canal or the hip- 
joint. Occasionally they burst in 
the alimentary canal, not so rarely 
in the lungs, and exceptionally in the peritoneum or 

Abscesses in the lung give rise to less disturbance 




FlG. 42. — Lumbar Abscess. 



larger vessels. 

than would be 

supposed ; in reality they present the rational and physical signs of a 
low form of localized pneumonia, of a chronic or subacute type. The 
bursting of an abscess into the bronchi is characterized by the discharge 
of a large quantity of pus, which is coughed up, the amount of dysp- 
noea, collapse, and danger from suffocation being dependent on the size 
of the abscess. The sudden discharge of pus is the indication of rupt- 



42 



ORTHOPEDIC SURGERY 



ure into the oesophagus, intestines, and bladder ; rupture into the ves- 
sels will necessarily, be fatal. No symptoms can be relied upon to give 
warning of the impending danger. 

The course of an abscess is toward absorption or increase. It may 
remain stationary in size and quiescent for a long time — a condition of 




FiG. 43. — Cervical Abscess. 



things which may be compatible with fair general health. Instances 
are not uncommon in which adults have been able to attend to active 
work and children to play about, although suffering from large cold 
abscesses. 

When absorption takes place the fluid contents disappear, and 
the caseous and purulent detritus, if present, in all probability be- 



TUBERCULOUS DISEASE OE THE SPINE. 



43 



comes encapsulated. This sometimes happens even in large psoas- 
abscesses. 

Abscess is most frequent in disease of the lumbar region, moderately 
frequent in the dorsal region, and least frequent in the cervical region. 1 

DIAGNOSIS. 

The ordinary clinical history of a case is of little value as an aid in 
establishing the presence of the disease. It maybe significant enough 
to create a strong suspicion of the existence of vertebral disease, but 
without definite physical signs a 
diagnosis of Pott's disease can- 
not be made. Too much impor- 
tance must not be allowed to the 
tendency of the parents to at- 
tribute the condition to trauma- 
tism. It should be mentioned 
that the absence of pain can in 
no way be assumed to show the 
absence of Pott's disease. 

The diagnosis, then, must 
be made wholly from the phys- 
ical examination. The chief phys- 
ical signs upon which one must 
rely can be divided into two 
classes: {a) those occurring 
from bony destruction; and (b) those dependent upon muscular spasm. 

(a) Signs due to Bony Destruction. — Since these are made evi- 
dent by the presence of angular deformity of the spine, which is the 
result of bony destruction, they are so conspicuous that they can 
scarcely be overlooked. And the prominence of one or more of the 
vertebral bodies, associated with muscular spasm, is a positive sign of 
the presence of the disease, unless it is the result of a fracture of the 
spine, or in adults the outcome of malignant disease, aneurism of the 
aorta, or some similar affection. In the larger number of cases, as they 
come to the surgeon, this bony deformity has occurred, and the diagno- 
sis can be made at a glance; but the most important class of cases, so 
far as the diagnosis is concerned, are those in which bony destruction 
has not yet begun, and in which the need of an early diagnosis is evi- 
dent, in the hope that it may lead to treatment which may be sufficient 
to prevent the occurrence of deformity. 

(b) Signs Arising from Muscular Spasm. — These are: 

i. Stiffness of the spine in walking and in passive manipulation. 

1 Townsend : Orth. Trans., vol. iv., 166.— Ketch: Orth. Trans., vol. iv., 200. 
— Dollinger : " Die Bhdlg. der Tub. Wirbelentz.." etc., Stuttgart. 1S9S. 




Fig. 44.— Retropharyngeal Abscess. 



44 ORTHOPEDIC SURGERY. 

2. Peculiarity of gait and attitudes assumed, according to the loca- 
tion of the disease. 

3. Lateral deviation of the spine. 1 

For all examinations children should be stripped. 

1. Muscular Stiffness. — On examining for muscular stiffness of the 
spine, the child is most conveniently laid face downward on a table or 
bed, and lifted by the feet. In a normal back the lumbar and lower 
dorsal spine can be markedly bent, and a general mobility of the whole 
column is seen. In patients in whom Pott's disease is present the re- 
gion affected is held rigidly by muscular contraction when manipulation 




FIG. 45.— Rigidity of Spine in Pott's Disease. (Children's Hospital Report.) • 

is attempted. In certain instances the erector spinae muscles stand out 
like cords when the child is lifted, and it is questionable how much im- 
portance should be attributed to this sign; it occurs in cases of hip dis- 
ease and in certain instances in excitable children in whom no joint 
disease is present. Lifting the patient by the feet in this way will 
show the existence of lumbar or lower dorsal rigidity, but it does not 
detect high dorsal Pott's disease. In lumbar Pott's disease lateral mo- 
bility of the spine, as well as antero-posterior flexibility, is lost. 

2. Peculiar Gait and Attitudes. — In considering the gait as a diag- 
nostic symptom of Pott's disease, one must be prepared to find any of 
the characteristic features absent. In general the walk is careful, 
steady, and military, and the steps are taken with such care that jars 
to the spine are avoided ; in other instances, however, the child walks 
1 Boston Med. and Surg. Jour., October 9th. 189c. 



TUBERCULOUS DISEASE OF THE SPINE. 



45 



with comparative freedom, even when the presence of the disease is 
manifest, and the well-known test of having- the child pick up objects 
from the floor may fail to detect anything. 

Assuming, then, the extreme importance of the early diagnosis of 
the disease when practicable, it becomes necessary to consider in detail 
the deviations from the normal signs, according to the region of the 
spine affected. 

Cervical Pott's Disease. — The most common symptom of the 
disease in this region, due to muscular rigidity, is the occurrence of 




FlG. 46.— Normal Flexibility of Spine. (Children's Hospital Report.) 

wry-neck with stiffness of the muscles of the back and neck. This is 
often accompanied by distressed breathing at night and intense occipi- 
tal neuralgia. The head is held sometimes in a much distorted posi- 
tion ; the most characteristic attitude is when the chin is supported in 
the hand; and when the patient turns sideways to look at objects, the 
whole body is turned. In severe cases one notices flattening of the 
back of the neck, with sometimes bony deformity. When spinal dis- 
ease occurs in this region the early symptoms are most often confused 
with sprains, muscular torticollis, and inflammation of the cervical lym- 
phatic glands. 

In disease of the upper cervical vertebrae the head, however, may 



4 6 



ORTHOPEDIC SURGERY. 




be held sharply flexed and sunk upon the chest. It may be hyperex- 
tencled with the occiput resting on the upper part of the spine, or it 
may be held laterally bent. 

From sprains the immediate diagnosis is almost impossible. In the 
early stages of sprains of the neck the head is often held stiffly and to 
one side; motion is resisted and is painful, muscular spasm is present, 

and in the case of children of unintel- 
ligent parents the history cannot be 
accepted as valid. 

From true muscular wry-neck the 
diagnosis is often extremely difficult. 
In congenital torticollis manipulation 
is generally not painful, and one 
muscle is firmly contracted while the 
rest are relaxed. In congenital cases 
the head and face are distorted, and 
the eyes often are not upon the same 
plane. In Pott's disease, on the other 
hand, the muscular fixation involves all 
the muscles, and movement in any di- 
rection is resisted, and is more apt to 
be painful. This applies fairly well 
to cases of anterior wry-neck ; but in 
cases in which the true muscular tor- 
ticollis is of the posterior variety, and 
is due to a contraction of the deeper 
muscles, the diagno- 
sis is much more dif- 
ficult, for no one 
muscle is contracted 
and movement is lim- 
ited by a general 
muscular resistance. 
The differential 
diagnosis can be 
most easily made by 
putting the patient 
to bed and seeing if the application of extension is sufficient to over- 
come the distortion, as it will do in the course of a few days if due 
to Pott's disease. Rheumatic torticollis simulates cervical Pott's dis- 
ease so closely that the physical signs are not sufficient at first to differ- 
entiate the affections. 

Inflammation of the lymphatic glands of the neck may give rise to a 
position of the head simulating wry-neck, associated with muscular spasm. 



J 



v 




FIG. 47.— Child with Dorsal Pott's Disease Picking up Object 
from Floor. 



TUBERCULOUS DISEASE OF THE SPINE. 47 

Upper Dorsal Pott's Disease.- — In this region detection is the 
most easy because any bony destruction at once results in angular de- 
formity, on account of the posterior curve of the spine in this part, and 
it is on this deformity that one must depend rather than on symptoms 
due to muscular stiffness. 

The shoulders are, however, held high and squarely, the gait is mili- 
tary and careful, and lateral deviation is almost certainly present. In 
Pott's disease, paralysis may exceptionally be the first perceptible 
symptom. 

From round shoulders, Pott's disease is generally to be distinguished 




Fig. 48.— Normal Child Picking up Object from Floor. 

by the fact that in the former the spine is flexible and the deformity 
rounded and not angular. The distinction is generally easily made. 

Lumbar Pott's Disease. — Vertebral disease in this region of the 
spine is difficult of detection on account of the anterior curve of the 
spine in the lumbar region, so that in any moderate amount of destruc- 
tion of the lumbar vertebral bodies no posterior angular curvature is de- 
veloped, and it is only in the later stages of the disease that any angu- 
larity becomes prominent. The occurrence of deformity is preceded by 
a flattening of the lumbar curve. The attitude is that of lordosis, which 
in some cases becomes very marked ; the gait is military and careful, 
and lateral deviation is generally present, sometimes to a very marked 
degree. It is in this region of the spine that it is most conspicuous. 



4 8 



ORTHOPEDIC SURGERY. 



In many instances of lumbar Pott's disease the first noticeable 
symptom is a limp, which is due to unilateral psoas contraction, the 
result perhaps of abscess or perhaps only of psoas irritability. Psoas 
contraction must be set down as one of the common symptoms of lum- 
bar Pott's disease. ' If the child is laid on its face and an attempt is 
made to flex the lumbar spine, it is found to be entirely rigid. Any 
attempt to hyperextend the leg in this position leads to the detection 
of the slightest psoas irritability. 

Lumbar Pott's disease is occasionally mistaken for single or double 
hip disease, or is regarded as a rhachitic curvature. 

The differential diagnosis between lumbar Pott's disease and hip 




Fio. 



-Attitude Assumed in Dorsal Pott's Disease when Rising- from Floor. 



disease is at times difficult, although it is not generally considered so. 
When the hip symptoms are due to Pott's disease and are caused by 
psoas irritability, the restriction of motion in the hip is simply in the 
loss of hyperextension, while abduction and internal rotation are free 
and not affected. This limitation of motion in only one direction is 
generally sufficient, in connection with the other symptoms, to establish 



TUBERCULOUS DISEASE OF THE SPINE. 49 

the presence of Pott's disease. On the other hand, in some cases the 
limitation of the hip's motion is in all directions, and simulates very 
closely the limitation of true hip disease. 

Another element which leads to the confusion of the two affections 
is the rigidity of the lumbar spine which often occurs as an accompani- 
ment of acute hip disease. If a child with hip disease is laid upon its 
face, and an attempt made to flex the lumbar spine by lifting the feet 
from the table, the irritability of all the muscles is so great that often 
the lumbar spine will appear to be completely rigid, and only a very 
careful examination will show that this is secondary to the hip dis- 
ease. 

RJiachitic deformity of the spine is a posterior curvature often so 
sharp as to be angular. It occurs at the junction of the dorsal and the 
lumbar regions. This junction is also a frequent site of Pott's disease. 
Muscular stiffness may not be present. 




FlG. 50.— Examination for Psoas Contraction. (Children's Hospital Report.) 

Rhachitic curvature of the spine is characterized by persistent stiff- 
ness in most cases, so that if the child is laid upon its face, and an at- 
tempt is made to flex the spine, the curve is not obliterated. The 
symptoms, therefore, are the same that would be presented by Pott's 
disease occurring under the same conditions, and much dependence 
must be placed upon the coexistence of rickets. It is often of use to 
treat such cases by rest on a frame, and if the curve is rhachitic, mo- 
bility will be restored to the back within the course of a few months. 

The Diagnosis of Abscess. — The diagnosis of a well-developed ab- 
scess in Pott's disease rarely presents any difficulty, but in certain in- 
stances their occurrence is attended with peculiar symptoms which 
may give rise to some obscurity. In the cervical region the most com- 
mon seat of abscess formation is in the back wall of the pharynx, where 
it often persists for some time unrecognized, giving rise to a peculiar 
series of respiratory symptoms. The pharyngeal wall is pushed for- 
4 



50 ORTHOPEDIC SURGERY. 

ward, and the child breathes at night with a peculiar snoring respira- 
tion, which is to a certain extent characteristic. There is some diffi- 
culty in swallowing food ; the pain is apt to be severe; and occasionally 
a swelling extends so much to the side as to be noticeable at the side of 
the neck. The finger introduced into the mcuth comes upon a project- 
ing swelling of the back of the pharynx, which is, characteristic and not 
to be mistaken. 

In the dorsal and lumbar region the abscesses point for the most 
part in the loin, or follow down the course of the psoas muscle to ap- 
pear in the upper part of the thigh or groin. Appearing in the back, 
the abscess is not likely to be mistaken for anything unless for an ab- 
scess of the back muscles or a lipoma. 

Psoas abscess causes limitation of hyperextension of the hip, and 
therefore a limp. In the iliac fossa a resistant or fluctuating tumor is to 
be felt. When abscess is present, if the child is laid on the face, hyper- 
extension of the hip on the affected side will be found to be limited. 

The Diagnosis of Paralysis. — Paralysis in Pott's disease, although 
ordinarily one of the later symptoms, may occasionally precede the de- 
formity and be the first sign of the presence of vertebral disease. 
Such cases are not so rare that they should be overlooked. The oc- 
currence of myelitis in a young child should be considered as extremely 
suspicious, and as being more likely due to Pott's disease than to any 
other cause, even if the signs of vertebral disease are obscure or appar- 
ently absent. In general the paralysis is preceded by a stage of the 
disease in which pain is much increased. Ordinarily one of the first 
demonstrable signs is an increase of the patella reflexes, with perhaps 
ankle clonus. 

Sprain. — It is difficult at times to differentiate a sprain of the ver- 
tebral column from Pott's disease. After a fall in which the back has 
been wrenched, a child begins to walk stiffly and to complain of pain in 
the back and perhaps in the legs. Attitudes characteristic of Pott's 
disease are assumed, the trunk is supported with the hands upon the 
thighs, the back is kept stiff in stooping, and passive manipulation 
shows that muscular rigidity is present. At an early stage a diagnosis 
is sometimes clearly impossible. But in sprains of the back the ten- 
dency is to a rapid recovery under proper conditions, and the result 
establishes the diagnosis. Severe sprains of the back are comparative- 
ly rare in childhood, but in adult males engaged in laborious occupation 
cases of strain are more common than cases of Pott's disease. The 
diagnosis is one which should be made in childhood with very great 
reserve. 

Rotary lateral curvature of the spine is an entirely different affec- 
tion from Pott's disease. It is not the result of a tuberculous destruc- 
tion of bone, but is the result of a distorted and abnormal process of 



TUBERCULOUS DISEASE OF THE SPINE. 51 

growth. It is characterized not by an angular projection of the spine 
backward, but by a gradual curve of the spine laterally with a rotation 
of the vertebral column on its long axis. Pain is not present, and the 
recognition of the affection is generally due to an alteration in the out- 
lines of the trunk and a prominence of the shoulder or hip. 

In most cases the diagnosis is not at all obscure. But in the course 
of Pott's disease at an early stage a lateral deviation may be present, 
which may be mistaken for lateral curvature. On a careful examination 
it will, however, be found that a stiffness of the back is present which is 
never seen at an early stage of lateral curvature. In some instances care- 
ful and repeated examinations are needed to establish a positive opinion. 

A lateral deviation takes place also sometimes in old cases of Pott's 
disease in connection with an old kyphotic curve destruction of bone 
greater at one side than at the other. 

Hyperaesthetic spine, also termed the hysterical spine and the neu- 
romimetic spine, is characterized by tenderness in certain portions of 
the back, sometimes accompanied by pain or ache. This condition is 
more common in neurotic persons, but may be seen in others who have 
been suffering from nervous exhaustion from any cause. It generally 
follows some slight or severe accident and as a rule occurs in persons 
with weak back muscles. The tenderness may be intense and mani- 
festly exaggerated, or it may be only slight and confined to small spots 
in the lower cervical and upper dorsal or in the upper lumbar region. 
As a rule, no real stiffness in the back is present, but in severe cases, 
or in cases which have remained in bed for some time, muscular stiff- 
ness may be present. This condition is sometimes seen after railway 
accidents. In the cases that are termed "railway spine," abnormal 
projection or deformity in the spine does not exist, although lax liga- 
ments and weak muscles permit a flexed condition of the spinal column 
in standing, which may make one or two vertebrae unduly prominent as 
the patient stands erect, but this prominence disappears in recumbency. 
Referred pains, or the attitude and gait characteristic of Pott's disease, 
are absent. A hyperaesthetic spine occurs in adults, and especially in 
growing young girls ; it may exceptionally be seen in children. 

Malignant disease of the spine presents, when a projection is found, 
a more rounded and less sharp projection than is seen in the beginning 
of caries. Carcinoma of the spine is usually secondary. The symp- 
toms, however — ■ pseudo-neuralgias, paresis, paralysis, and muscular 
stiffness — are the same in both, and sometimes only a conjectural diag- 
nosis can be made. Sarcoma of the spine is very rare in childhood. 

Much the same may be said of the curvatures of the spine caused 
by tmeurism, except that the diagnosis is usually made by auscultation 
or by the rational symptoms before the spine is noticeably affected. 

Tumors pressing on the spinal cord may cause stiffness of the back 



52 ORTHOPEDIC SURGERY. 

and pain referred to the peripheral ends of the nerves. Angular de- 
formity, however, is absent, and the symptoms of nervous disturbance 
predominate over the ordinary ones of Pott's disease. 

Osteomyelitis of the spine may be secondary or primary. The 
transverse and articular processes as well as the vertebral bodies may 
be affected, and tenderness is present at the seat of disease. Suppura- 
tion elsewhere occurs in sixty per cent of all cases. There is much 
constitutional disturbance, fever is high, and the course rapid. CEdema 
of the affected parts appears early ; abscesses of a very acute and ex- 
tensive character as well as paralysis are other early features. The 
formation of a kyphus of any extent is unusual. 

Spondylitis deformans of the spine is an affection most frequent in 
adult life, characterized on superficial examination by stiffness and 
some arching of the spine; there are usually little muscular spasm and 
no unusual projection of the spinous processes; in some instances the 
ribs are ankylosed to the spine, so that no expansion of the chest is 
possible. Stiffness of the back is present, but the whole spine is rigid 
and other joints may be involved. These cases may occur in connec- 
tion with gonorrhoea. Patients suffering from this affection may have 
neuralgic or pseudo-neuralgic pains of the nerves issuing from the spine 
at the affected part. 

Spondylolisthesis, or dislocation of one of the lumbar vertebrae, may 
cause pain, lordosis, and peculiarity of gait and posture. There is no 
characteristic kyphus and the diagnostic signs of spondylolisthesis will 
establish its existence. 

With regard to the symptoms of sacro-iliac disease, perinephritis, 
and appendicitis, it may be said that a mistake in diagnosis may hap- 
pen, but that ordinarily there is no obscurity. It should, however, be 
borne in mind that in appendicitis and in perinephritis, when an ab- 
scess is present, a contraction of the thigh may occur, resembling that 
seen in psoas abscess. The absence of a projection or irregularity of 
the back, and the power of muscular movement of the back in these 
cases, will help to establish the fact that they are not due to disease of 
the spine. 

Skiagrams in early cases of Pott's disease rarely aid in the diagnosis, 
but when marked osseous change has taken place the fact may be seen 
in certain regions of the back. 

PROGNOSIS. 

Pott's disease will always be regarded as one of the most formidable 
of diseases; its long course, the deformity entailed, the severity of the 
complications, and the occasional termination in death give both to the 
surgeon and to the non-professional public a natural dread of the affec- 
tion. These inferences are, however, drawn from the severer cases, 



TUBERCULOUS DISEASE OE THE SPINE. 53 

and facts show that the disease has a tendency to spontaneous recovery, 
that in certain parts of the spine deformity can be prevented, and that 
in few affections does the work of the surgeon give greater relief than 
in Pott's disease. 

Mortality. — No statistics of value exist as to the percentage of mor- 
tality and recovery. 

The occurrence of severe pain, fever, and rapid increase of the de- 
formity are unfavorable from a prognostic point of view. The general 
condition of the patient and the family history are of importance in the 
prognosis. The occurrence of paralysis does not affect the prognosis 
unfavorably. The occurrence of abscess makes the prognosis slightly 
less favorable, because abscess accompanies the severer cases. 

Forty-nine cases of psoas abscess operated on at the Children's Hos- 
pital in the decade ending in 1900 were investigated as to end results by 
one of the writers. Thirty-five per cent were known to have died and 
53 per cent to be alive shortly after the close of the decade. Of cases 
operated on in the first five years 50 per cent were dead, and of cases 
in the last five years 26 per cent, had died. 

The percentage of recovery, however, in patients under better hy- 
gienic conditions than hospital patients is more favorable. 

The tendency of the deformity is to spontaneous increase, and this 
is specially marked in the upper dorsal region. Instances of arrest 
without marked deformity are not so very rare in upper cervical disease 
and in lumbar disease, but in the upper and middle dorsal regions the 
tendency is for an increase of the deformity proportionate to the extent 
of the disease. In many cases some arrest of the growth of the whole 
child takes place apart from the loss of vertebral substance. The cure 
from Pott's disease may be so complete as to permit normal childbirth, 
provided no distortion of the pelvis has taken place. 1 

No reliable statistics exist as to the amount of time necessary to 
establish a cure in Pott's disease. The disease varies greatly as to its 
self-limitation in individuals, and according to the situation and extent 
of the disease. Necessarily there will be a difference in individual 
cases in the result of treatment. 

It may be said that, as the bodies in the cervical region are smaller 
than those in the lumbar, the time required for self-limitation here is 
shorter than in the lumbar region. In the latter region, also, the super- 
incumbent weight is a more important factor than in the upper part of 
the spine. 

The occurrence of bony formation firm enough to support the col- 
umn in its weight-bearing function must be a process requiring a long 
time for its completion, to judge from it as observed elsewhere; and 
nowhere is protection more urgently demanded during convalescence 
'-Trans. Amer. Orth. Assn., vol. iv. 



54 ORTHOPEDIC SURGERY. 

than in the vertebral column. This is especially true in growing chil- 
dren. Cases of supposed cure of Pott's disease have redeveloped 
symptoms at the period of rapid growth at the approach of puberty. 
It should especially be borne in mind that protection to the spine may 
be needed at this period. 

TREATMENT. 

This varies according to the stage and condition of the pathological 
process. 

When the destructive ostitis is acute and extensive the affected 
bone should be protected from all jar and pressure, both that due to 
superimposed weight and attitude. When cicatrization has begun the 
spine should be protected so that activity necessary for health may not 
cause injury in the imperfectly healed bone structure. 

Protection is necessary until the previously inflamed bone has be- 
come cicatrized so thoroughly as to withstand without injury jar and 
superimposed pressure. 

A growing spinal column, even if the vertebrae have recovered from 
caries, may need support to prevent an increase of curvature by abnor- 
mal growth. 

Treatment, therefore, is different in the acute, the subacute, and the 
convalescent stages. In the acute stage recumbency is the most effi- 
cient method. In the subacute and convalescent stage ambulatory 
treatment with more or less efficient spinal protection is advisable. 

Treatment by Recumbency 
If the patient lies upon his back or upon his face on a hard surface, 
there is no superincumbent weight pressing upon any portion of the 
spine. If the patient lies upon his back upon a spring-bed, and the bed 




-Gas-Pipe Frame. 

sags, the spine is of course bent, and pressure upon the vertebrae, pro- 
portional in amount to the extent of the curve, results. 

If treatment by recumbency is to be adopted, it is not sufficient 
simply to place the child in bed. Sagging of the mattress, moving of 
the patient from side to side, twisting and turning are all injurious, in 
that they cause motion between the vertebrae and change interarticular 
pressure, both of which are undesirable. 

It is necessary that the child should be fixed in a suitable position 
in bed. This can be done by securing the child in such a manner that 



TUBERCULOUS DISEASE OE THE SPINE. 



55 



the vertebral column at the seat of disease is arched forward, diminish- 
ing the interarticular pressure. The simplest way of doing this is by 
means of a frame. 

The rectangular bed frame (Chapter XXI., 9) consists of a 
stretcher of heavy cloth attached to a rectangular gas-pipe frame. 

The child lying upon this frame can be secured by means of straps 
across the shoulders and pelvis and knees, and can be carried about 




FlG. 52. — Method of Securing Child to Bed Frame for Recumbent Treatment of Dorsal Pott's 

Disease. 

without jar. When the frame is placed upon the bed, the cloth cover- 
ing is no more uncomfortable than the surface of the bed. 

But simple recumbency is not alone sufficient to promote cicatricial 
ostitis. The removal of intervertebral pressure is also necessary. 
This is to be accomplished by arching the spinal column forward at the 
point of the kyphotic curve. When the cicatrization has not progressed 




Fig. 53.— Gas- Pipe Silva Frame. 

so far as to produce ankylosis, correction (partial or complete) of the 
curve can be effected by placing under the curve of the child lying upon 
the back a firm pad, pressing upon each side of the spinous process, 
and sufficiently high to press this part upward while the rest of the 
spinal column drops back by its own weight. The pads can be fur- 
nished by properly folded sheets or towels, by felt padding, or by a 



56 



ORTHOPEDIC SURGERY. 



plaster-of -Paris back moulded to a corrected position of the spine, or by 
arching the frame at a desired point, as has been suggested by Silva 
and Whitman. 1 This holds the spine hyperextended throughout its 
length. In this way greater separation at the diseased region is ob- 
tained perhaps more easily than on the ordinary frame. The ordinary 
frame, however, properly padded, answers every, purpose. 

A child undergoing treatment on the frame should be turned once 
a day to have the back washed, rubbed with alcohol, and powdered. It 
is important that there should be no pads in the median line immedi- 




FlG. 54.— Traction in Cervical Caries. (Children's Hospital Report.) 

ately above or below the deformity, but that the pads should lie entirely 
outside of the line of the spinous processes. To secure better fixation 
it may at times be necessary to place pads under the lumbar region. 

In cervical caries head traction in a recumbent position will be 
found of use in cases of torticollis ; and in severe neuralgia from cervi- 
cal caries the relief afforded is often very marked. Traction can be 
furnished by means of a head sling passing over the forehead and oc- 
ciput, which is attached to a weight and pulley running over the head 
of the bed or to the head of the frame. The counter pull may be fur- 
nished by the weight of the body in case the head of the bed is raised, 
by a downward pull upon the trunk through a waist band, or by means 
of traction applied to the limbs. 

Treatment by recumbency will be found of service, either alone or 
in conjunction with other methods, in cases with acute symptoms, in 
cases of severe cervical disease, in cases with marked lateral deviation 
1 Whitman's " Orth. Surg.," 2d ed., p. 91. 



TUBERCULOUS DISEASE OF THE SPINE. 



57 



of the spine, in paralysis, in cases of psoas contraction and abscess, in 
cases which do not progress well under ambulatory treatment and 
which lose flesh and strength, and in very small children in whom the 
difficulty of fixing the spine by apparatus is great. 

Patients who have been suffering will often be found to gain flesh 
after the relief afforded by recumbency, though the muscles in the 
limbs diminish in size. 

Treatment by recumbency, if used, should be thorough. Half 
measures have the evils of the imprisonment without the benefit of fix- 
ation. The limit of its usefulness is usually marked by the restlessness 
of the patient. In children the irksomeness of the confinement is 
borne readily; but in adults the imprisonment constitutes a serious 
obstacle to the employment of the method. 

The objections to treatment by recumbency are evident. Pott's 
disease is a tuberculous affection and close confinement is injurious to 




FIG. 55. — Ward Carriage for Recumbent Treatment of Pott's Disease. 

patients with a tuberculous taint. Patients of this sort need all possi- 
ble help from fresh air and exercise, and the method of treatment by 
recumbency for years, formerly the only thorough method possible, is 
not now regarded as necessary in all cases. It must be remembered 
that all apparatus is necessarily imperfect from a mechanical point of 
view and must fail in wholly relieving the diseased vertebrae of their 
weight-bearing function, so that within its limitations recumbency is to 
be recognized as mechanically the most efficient mode of treatment and 
the least likely to encourage deformity. 



Ambulatory Treatment. 

Treatment by Plaster Jackets. — The purpose of the treatment by 
plaster jackets is to fix the spine so firmly that there will be no injury 
to the affected vertebrae from the iar incident to locomotion. 



58 



ORTHOPEDIC SURGERY. 



Plaster jackets (Chapter XXL, 1) are made by applying successive 
layers of properly prepared bandages to the patient's trunk, which has 
been placed in a suitable position. 

The patient during the application of a plaster jacket is either up- 
right or recumbent (on back or face), with or without a suspension or a 
traction pull. The application of the jacket by suspending the patient 
by the head and arms was the method introduced by Sayre, and has the 

advantage of ready application 
and has been of great benefit in 
curing a large number of patients 
unrelieved by former methods. 

Application of Jacket 
with the Patient Suspended. 
— Suspending a healthy person 
by the head diminishes the 
physiological curves (cervical 
and lumbar lordosis, dorsal ky- 
phosis), and the spine becomes 
straight so far as its formation 
will allow. 

In suspension, in old Pott's 
disease, it is only the physio- 
logical curves which are obliter- 
ated ; ' the sharp kyphosis is held 
too firmly by adhesions to permit 
correction. In earlier cases the 
intervertebral pressure is, in a 
measure, diminished at the point 
of disease by suspension; but 
suspension does not cause a dis- 
appearance of the sharp angular 
projections at the point of dis- 
ease, although the kyphus is 
diminished. 

The undoubted beneficial effect of a plaster jacket is due to its ser- 
vice as a fixation support in an improved position, although it was origi- 
nally supposed that a jacket could be applied so as to serve as a means 
for holding the diseased vertebrae apart, i.e., as a means of distraction. 
The treatment by plaster jackets requires care, for a poor jacket does 
harm rather than good by deceiving the physician and the patient. 
For the proper applying of plaster jackets, moreover, a careful atten- 
tion to detail is necessary. 

The patient's clothes are removed and a thin, tightly fitting under- 
1 Anders: Archiv f. klinische Chirurgie, 1889, Hi., p. 558. 




Fig. 56.— Sayre Headpiece for Suspension 
Pott's Disease. 



TUBERCULOUS DISEASE OF THE SPINE. 



59 



shirt is applied, put on so as to present no wrinkles. The patient is 
thickly padded by felt or sheet-wadding pads over the pelvis and two 
thick felt pads are placed longitudinally at the sides of the kyphus. 
The patient is then suspended ; the head is secured in a sling, which is 
attached to a strong cord playing in a pulley, or series of pulleys, fast- 
ened to a point above the patient's head. An assistant pulling on the 
cord raises the patient so that the heels are free from the floor. It is 
desirable to diminish the strain upon the neck, and padded loops con- 
nected with the bar, which is raised by the cord and pulley, can be 





FIG. 57.— Jury-mast Before Incorporation. Fig. 58.— Jury-mast and Plaster Jacket. 

passed under each axilla, or handles may be held in each hand, con- 
nected with cords which play over pulleys. 1 

The bandages are then wound smoothly around the patient. If 
the plaster is fresh and of the best quality, it should harden in five 
minutes. The hardening can be hastened by putting salt or alum 
in the water, but this makes the plaster somewhat more brittle. After 
the plaster is hard or nearly hard, the patient is to be placed on a soft 
flat surface, care being taken not to crack the plaster in so doing. The 
edges of the jacket are smoothed down and cut off if they press un- 
comfortably on the thighs or axillae. 

It is important that the jacket should be strong in front as well as 
behind, and should be wound as high as possible in front, in order to 

1 A. Thorndike : "Comparison of Different Methods." Am. Journ. Orth. 
Surg., vol. ii., 1. 



6o 



ORTHOPEDIC SURGERY. 



prevent the spinal column from falling forward. If the jacket becomes 
broken or softened, it should be removed and another applied. 

If the disease is in the cervical region, the plaster bandages can be 
carried up around the back of the head and neck and under the chin, 
leaving the face and upper part of the head exposed, and so fixation 
and support may be obtained in that part of the vertebral column. 
This method of fixation has certain manifest disadvantages in lack of 
cleanliness, clumsiness, and unsightliness, but it is thorough and fur- 
nishes an excellent support and is by no means uncomfortable for the 
patient. 

It is more efficient than the head sling attached to a bent rod ex- 
tending above the head and incorporated below into the plaster jacket — 





Fig. 59.— Paper Jacket. (Children's Hospital 
Report.) 



FIG. 60. — Hammock Frame for the Applica- 
tion of Jackets during Recumbency on the 
Face. Ready for use. 



the " jury mast " devised by Sayre. The required degree of suspension 
varies with the seat of the disease and the firmness of the curve; but 
complete suspension is rarely necessary in cervical and dorsal cases, as 
removal of the superimposed weight can be accomplished without this. 
Application during Recumbency on the Face. — The patient is 
laid face downward with the arms above the head on a hammock, which 
consists of a stout cloth a little wider than the child, stretched over the 
ends of a rectangular gas-pipe frame. One end of this cloth is attached 
to the upper end of the frame and does not move. The other end is 
attached to a movable bar connected with the other end of the frame 
by a rope. By a ratchet this bar can be pulled upon and the tension of 
the cloth regulated. The hammock maybe made very tight or allowed 



TUBERCULOUS DISEASE OF THE SPINE. 



61 



to sag to any extent. In this way hyperextension of the spine may be 
produced as desired. 

The hammock cloth is cut along the sides of the child's body longi- 
tudinally and the parts not under the child's body are drawn aside and 
fastened or cut away. The plaster rollers are then applied, including 
both child and hammock. 

Instead of the stretched hammock cloth, the patient may be placed 
on two pieces of stout webbing stretched along the length of a rectan- 
gular frame. These should be placed sufficiently near together to sup- 
port the trunk without pressure upon the chest. Cross straps of web- 
bing are necessary at the hips and shoulders when the jacket is applied. 




Fig. 6i. — Method of Applying a Plaster Jacket in Recumbency, on the Hammock Frame. 

The webbing straps are untied and patient released, after which they 
are pulled out. 

This method, as has been demonstrated by Brackett, 1 is serviceable 
for lumbar and low dorsal disease, but is not as satisfactory in cases at- 
tacking the spinal column higher up, requiring close apposition of the 
bandages in the upper part of the front of the chest. 

This difficulty and the necessity of raising the shoulders and hyper- 
extending the spine above the diseased region can be met by the use of 
an appliance devised by one of the writers 2 (Fig. 66). 

The apparatus consists of an oblong gas-pipe frame of the ordinary 
pattern. Fastened to this near the middle and hinged so as to be 
'Trans. Am. Orthop. Assn., vol. viii., p. 160. 
" 2 Lovett: American Medicine, vol. iv., No. 10, p. 273- 



62 



ORTHOPEDIC SURGERY. 



raised to any degree is another section of gas-pipe lying on the frame 
proper and of the same shape and size as the upper half of the frame. 
To this movable section is fastened at right angles to it and movable on 
it a gas-pipe bridge, rising about eighteen inches from the movable sec- 
tion. 

The patient lies face downward on two straps of webbing, lying one 
over the other, run from each of the buckles at the bottom of the frame. 
The lower pair of these strips are tightly drawn and run to the buckles 




FlG. 62.— Plaster Jacket. Front view. 



Fig. 63.— Plaster Jacket. Back view. 



at the end of the movable section. The upper pair are loosely fast- 
ened to the bridge over the movable section. 

The patient should be placed in such a way that the seat of disease 
comes opposite the hinge where the movable piece is attached, and the 
head and pelvic webbing supports are adjusted to their proper places. 

The deformity must be very heavily padded by thick felt pads placed 
on each side of it. The jacket is then applied in the usual way up to 
and only as far as the level of the apex of the deformity and allowed 
to harden. After the plaster has hardened, a piece of webbing or 
stout cotton bandage running from side to side of the main frame (not 
attached to the movable section) is passed over the upper back edge of 



TUBERCULOUS DISEASE OF THE SPINE. 



63 



the jacket and when this is fastened in place the movable section of 
the frame is lifted until the desired correction is obtained at the seat of 
the deformity. When the desired point is reached the movable sec- 
tion is fastened in position and a few turns made with a plaster band- 
age, going up two or three inches above the deformity. Then the 
straps running to the end of the movable section which have been the 
chief hyperextending force are unbuckled and turned up over the 
bridge, and the patient remains suspended by the straps running from 





FIG. 64.— Plaster Jacket. Side view. 



FIG. 65.— Plaster Jacket and Head- 
piece. (Wullstein.) 



the bottom of the frame to the bridge. These are closely applied to 
the front of the chest and shoulders and permit the upper part of the 
jacket to be firmly applied around the sternum, upper ribs, and front of 
the shoulders, holding the chest well back. 

When the plaster has hardened the webbing strips are unbuckled 
and the patient is removed from the frame. The webbing strips are 
easily pulled out from under the jacket and are used again. 

If it is desirable to diminish lumbar lordosis, the thighs should be 
flexed on the body as the patient lies on the face. 

Application of a Jacket with the Patient Placed upon the 
Back. — In applying a jacket with the patient lying upon the face some 



64 



ORTHOPEDIC SURGERY. 



compression of the chest and flattening of the abdomen take place. 
To avoid this, a jacket can be applied with the patient placed upon 
his back. If this were done with the patient lying upon a stretched 
sheet, the sagging of the material would prevent the necessary hyper- 
extension of the spine. 

To obviate this, an appliance devised by Metzger and modified by 
Goldthwait, Brackett, and R. T. Taylor, will be found of assistance. 




PlG. 66.— Frame with Movable Section for Application of Plaster Jackets. 

An upright steel rod is arranged with a forked top on which can be 
placed two attachable pad plates. The rod fits in a stand and can be 
raised or lowered by means of a screw. If the patient is made to lie in 




FIG. 67- — Frame with Movable Piece in Use. 



such a way that, while the head, shoulders, and pelvis are supported 
the kyphus rests upon the pad plates, a hyperextending force is exerted 
on the kyphus. As the rod bearing the pad plates is raised or lowered, 
the pressure on the kyphus is increased or diminished. Any desired 
amount of hyperextension of the spine can be furnished. 

Exaggerated lordosis can be prevented by flexing the thighs. 

Brackett has attached the upright rod to a frame, such as is used in 
the hammock application of jackets. 



TUBERCULOUS DISEASE OF THE SPINE. 



65 



Goldthwait l and R. T. Taylor have employed the principle by 
means of two movable stands, the former employing two parallel steel 
rods connecting the uprights as a support to the lower part cf the back, 
which are removed after the jacket has hardened. 

R. T. Taylor 2 has combined the arrangement with a mechanism for 




FlG. 68. — Frame for Applying Jacket with Patient Recumbent upon the Back. (Metzger- 

Goidthwait.) 

a pull and a counter-pull. The jacket is applied in the usual way and 
the patient placed in the desired position. 

Jackets Applied with the Patient Sitting. — The patient may 
be seated during the application of the jacket if it is desired to prevent 
lordosis in the lumbar region. 

In disease of the lumbar region, since lordosis is desirable to sepa- 




FlG. 69. — Portable Frame for Applying Plaster Jacket. (Metzger-Goldthwait.) 

rate the lumbar vertebrae, suspension is not necessary. The jacket can 
be applied with the patient steadied and the back arched forward to 
secure exaggerated lordosis. 

R. T. Taylor 3 has applied jackets for disease of the spine with the 
patient seated, using an arrangement which can be readily understood 
by the accompanying illustration (Fig. 70). 

In adult cases of caries of the spine in the upper dorsal or cervical 
regions with slight kyphus, jackets can be applied with the patients 
seated, with the slight correction afforded by head-sling traction. 

1 Trans. Am. Orth. Assn., xi. , 89. 

2 Johns Hopkins Bulletin, xii., 119. 

3 Johns Hopkins Bulletin, February, 1895, No. 45. Trans. Am. Orth. Assn., 
vol. xii., p. 119. 

5 



66 ORTHOPEDIC SURGERY. 

It is desirable that the surgeon should familiarize himself with the 
application of plaster jackets by the different methods mentioned, as it 
will be found that they are of assistance in different cases. Frightened 
children are less alarmed if placed upon a hammock than if suspended. 
A jacket applied with the patient placed upon a hammock is useful in 
low dorsal caries, but is less satisfactory in mid or upper dorsal caries. 
By the aid of the correcting appliance an efficient jacket can be applied 
in upper dorsal caries with the patient prone. A jacket where espe- 
cial attention is needed in front is thus readily applied with the patient 
lying upon the face. Where hyperextension is needed it can be ac- 
complished best by means of the apparatus described for application 
of the jacket in back recumbency. The seated position is most con- 
venient for the patient ; for simple cases with slight deformity, where 
much hyperextension is not needed and where the head is to be in- 
cluded in the jacket, suspension with the patient upright will be found 
the most satisfactory method. 

It is sometimes the case that a jacket may be applied which appar- 



FlG. 70.— Child in Recumbent Kyphotone Ready for Application of Jacket. (R. T. Taylor.) 

ently is furnishing satisfactory support, while the surgeon may wish to 
determine the exact amount and seat of efficient pressure. A simple 
method of determining this, without injury to the jacket, has been em- 
ployed by Dr. A. Thorndike. A narrow longitudinal slit is cut for a 
sufficient distance in the back of the jacket, which is made thick for 
the purpose, and the position of the spine held in the jacket determined 
by taking a tracing of the spinous processes through the slit. 1 

The most acceptable form of permanent jacket is one applied over a 
seamless woven shirt. These shirts are made very long and reach the 
knees ; one of them is put on the patient and the jacket applied over 
it. The lower part of the shirt is then turned up over the outside of 
the jacket and reaches to the top of it. It is there stitched to the up- 
per part of the shirt along the upper edge of the jacket. This, how- 
1 Am. Journ. of Orth. Surgery, ii., 2. 



TUBERCULOUS DISEASE OE THE SPINE. 67 

ever, is not done until the jacket has been removed, by splitting it 
down the front and gently springing it open. The edges of the cut are 
stitched with leather and a row of hooks is provided on each side 
with which to lace it together. A jacket is thus provided, which is 
covered inside and outside with soft woollen material, which can be 
removed for purposes of cleanliness and reapplied to the patient, 
who should be, of course, suspended or laid on the face for each reap- 
plication. 

Removable Jackets. — After a jacket has been applied by any one 
of these methods, it may be converted into a removable jacket. Re- 
movable jackets are not, however, such efficient supports as fixed jack- 
ets during the acute stage of the disease. They are, as a rule, to be 
used in convalescent cases, in exceptional cases in the acute stage when 
the skin is very sensitive and requires bathing, when sloughs or excori- 
ations are present, and in similar conditions. 

As a substitute for plaster jackets, corsets are made of leather 
(Chapter XXI., 3), felt, wood, aluminum, celluloid (Chapter XXI., 2), 
papier-mache, silicate of potash, etc. The plaster jacket, which is ap- 
plied in the usual way, is removed with care so as to preserve its shape. 
A cast of plaster of Paris is taken from the jacket, and on this as a 
form a corset is made of leather (which when wet can be stretched 
tightly over the form). After the plaster jacket has become hard, it 
can be split and furnished with eyelets and lacings ; it can then be ap- 
plied on the patient, who is suspended, as in the application of a plas- 
ter jacket. Rawhide stretched over a cast, thoroughly dried and left 
until hardened, furnishes a corset which is both light and firm. The 
process of manufacture requires attention and detail. The same is 
true of a jacket made of celluloid. Both of these corsets curl unless 
equally dried, before using, on the inner and outer side. 

In the upper dorsal and cervical region it is necessary either to add 
to the plaster jacket an appliance for securing the head (the varieties 
of which will be mentioned later), or to carry the plaster jacket over 
the shoulders and neck. A plaster collar applied simply to the neck, 
and not to the trunk, does not give sufficient support except in disease 
of the upper cervical vertebrae. 

TheyV/zj mast consists of a bent rod of steel running up from the 
jacket, following the curve of the neck and head to a point above the 
top of the head. To the end of this rod is attached a cross bar which 
carries a head sling. The lower end of the jury mast terminates in a 
metal framework, which is incorporated in the jacket. By raising the 
head sling the head can be pulled upward. But it is very difficult in 
practice to keep up continuous traction on the head in this way, and 
the inconvenience and unsightliness of the apparatus are objectionable. 

The chief objection to the treatment of Pott's disease with a perma- 



68 



ORTHOPEDIC SURGERY. 



nent plaster jacket is in the uncleanliness. Removable jackets and cor- 
sets are not firm. As a base for head supports in the upper dorsal and 
cervical regions a corset is not readily applied and is more unsightly 
than a well-fitted appliance ; but in the mid-dorsal and upper lumbar 
region the permanent plaster jacket must be regarded as the most effi- 
cient ambulatory fixative appliance. 

When a lateral deviation of the spinal column is present with Pott's 

disease, the jacket is preferable to 
any brace. 

In disease which is very low 
down, the jacket is often a more 
efficient and comfortable mode of 
treatment. For careless and igno- 
rant patients a jacket which is not 
removable is far preferable to any 
apparatus which they can misuse. 
Moreover, the cheapness of the 
jacket brings it within reach of 
many people who would otherwise 
have to go without treatment. 




FlG. 71.— Antero-Posterior Support Ap- 
plied. (Dr. H. L. Taylor.) 




Fig. 



-Taylor's Chest Piece. 



As to the method of application of a jacket, it is to be remembered 
that the object is to secure fixation of the spine in an improved posi- 
tion. As much force should be used as will secure this without caus- 
ing undesirable traumatism at the seat of the disease. Suspension 
alone is the least efficient of all means. Recumbency on the hammock, 
the kyphotone of Taylor, and the two frames mentioned (all of which 
induce an improved position by the local use of force) are the most effi- 
cient. It is desirable in severe cases to carry the jacket over the 
shoulders and to have the jackets durable enough to be worn for 
months. They should be changed with every care not to increase the 
deformity in the process, even temporarily. The method to be chosen 



TUBERCULOUS DISEASE OF THE SPINE. 



6 9 



will vary largely with the familiarity of the surgeon with that especial 
method. No one of the methods mentioned as efficient is to be advo- 
cated to the detriment of the other methods similarly classed. 

Treatment by Steel Appliances. 

The basis of ambulatory treatment of Pott's disease in the subacute 
or convalescent stage is fixation, as complete as possible, of the spine 





Fig. 73.— Aiitero-Posterior Brace for Dorsal Pott's 
Disease Applied. 



Fig. 74.— Antero-Posterior Brace for 
Pott's Disease ; showing Apron 
and Leather Gorget. 



in as advantageous a position as obtainable. This may be done by 
means of a properly made appliance. 

As the chief motion of the spine to be guarded against is the for- 
ward motion, the principle of the appliance is that of an anteroposte- 
rior support. This was first efficiently applied by Dr. C. F. Taylor, of 
New York, as a method of thorough treatment, as it involves skill and 
anatomical and pathological knowledge. 

The construction and application of a brace should be superintended 



7o 



ORTHOPEDIC SURGERY. 



directly by the surgeon, and not relegated to an instrument-maker. 
The details relative to the future result are fully as important as the 
application of a splint in any fracture, for the result will, in a great 
measure, depend on the accuracy of adjustment. For the construction 
of a splint a cardboard tracing of the back should be made at one side 
of the spinous processes. 

The simplest antero-posterior apparatus (Chapter XXL, 4) consists 
of two uprights of annealed steel. The uprights are joined together 
below by an inverted U-shaped piece of steel which runs as far down 
on the buttock as possible without reaching the chair or bench when 




1671 72 77 \Q72 73 75 76 (665 67 W 75 I&71 71 75 1661 65 70 




73 74 77 1864 



1669 70 75 76 



1869 70 76 77 



FIG. 75. —Tracing's showing Results of Brace Treatment as Carried Out by Dr. C. F. Taylor, 
c /, Two and three-quarters years, first and second lumbar disease, rive years' treatment ; 
II, eight years, eleventh and twelfth dorsal, four years' treatment ; III, four years, first 
lumbar, ten years' treatment ; IV, three and one-half years, six years' treatment ; V, five 
years, twelfth dorsal, first and second lumbar, nine years' treatment ; VI, five and one- 
half years, sixth and eighth dorsal, four j'ears' treatment ; VII, about eighteen, dorso- 
lumbar, eight years' treatment ; VIII, nine years, seventh to ninth dorsal, seven years' 
treatment ; IX, twenty years, five years' treatment ; X, ten years, eight years' treat- 
ment. (Dates are given with tracings ; the age given is that at which treatment was be- 
gun.) 

the patient sits down. Or the brace may end in a waistband. At the 
top the uprights end in shoulder pieces running over the shoulders. 

The brace, after being put together but before being finished, 
should be tried on the patient, who should be lying on his face. Any 
alteration necessary in the curves of the steel, in order to have the ap- 
pliance fit closely to the back along its whole length, can be made with 
wrenches. The brace can be faced with hard rubber or covered 
smoothly with leather. An accurate fit is essential ; the covering is 
merely a matter of detail. 

Accurately fitting pad plates covered with felt and leather or hard 
rubber are needed. In some instances, at the points of greatest press- 
ure, the bars of the brace, if well padded, answer every purpose. 
Buckles are needed at various levels. 



TUBERCULOUS DISEASE OF THE SPINE. 



71 



If properly designed the appliance will press firmly at the deformity, 
i.e., the pad plates and pressure should be uniform at this point and 
closely fitted to the contour of the deformity in all planes. The appli- 
ance will also touch necessarily at the top and bottom, but the chief 
pressure should be at the kyphus. Variations from this type of con- 
struction will naturally be of use. Nicety of workmanship in the man- 
ufacture of a brace is of relatively secondary importance. The essen- 




lOmos 



3 years 





llmos 



9 10 



12 



5mos 9mos 

Fig. 75a.— Results of Hyperextension Treatment (Goldthwait). 1, At beginning of treatment ; 
2, ten months later ; 3, at beginning of treatment ; 4, same, three years later ; 5, at begin- 
ning of treatment ; 6, seventeen months later ; 7, at beginning of treatment ; 8, seventeen 
months later ; 9, at beginning of treatment ; 10, same, five months later ; 11, at beginning 
of treatment ; 12, same, after nine months. 

tial is that it should be mechanically efficient in meeting the indications 
of fixation. The construction of the brace does not necessarily involve 
expensive workmanship, and need not be anything beyond the skill of a 
village blacksmith. It should be borne in mind that, besides accuracy 
of fit and proper design, it is of importance that the apparatus be stiff 
enough not to yield as the weight of the trunk falls upon it, inasmuch 
as yielding involves intervertebral pressure. This is true not only of 
the uprights, but also of the band. A stiff appliance, if properly fitted, 
can be made as comfortable as a yielding one, and is much more efficient. 



72 ORTHOPEDIC SURGERY. 

An error in accuracy of fit may be sufficient to furnish insufficient 
protection and cause relapse. Moreover, it is necessary that the patient 
should be seen often enough to keep the brace fitting accurately, for 
the deformity may increase or diminish at any time. In such a case 
the brace becomes inefficient. 

It is, of course, essential that the trunk be properly secured to the 
brace. This can be done in part by means of an apron, which covers 
the front of the trunk, the abdomen, and the chest, reaching from the 
clavicles nearly to the symphysis pubis. The apron is provided with 
webbing (non-elastic) straps, which are fastened into buckles attached 
to the brace. Padded straps, passing from the top of the brace around 
the arms, under the axillae, and attached to buckles in the middle of the 
brace, help to secure it ; but the scapulae, being movable, cannot be re- 
lied upon alone to fix the trunk, and the apron must be furnished with 
straps at the top, which pass over the shoulders to buckles in the top 
of the brace. 

In adults it is often convenient to have the apron split down the 
front and provided with webbing straps and buckles, so that the patient 
can adjust it himself by tighening the straps in front. 

To secure a proper hold upon the upper segment of the body in 
dorsal disease some unyielding and rigid chest piece is necessary. 
Taylor's chest piece acts by means of hard-rubber pads at the upper 
part of the chest, connected by a steel rod, which keeps the brace 
closely against the back. The pads of the chest piece may be made of 
hard rubber and fit in below the clavicles, where they cause no discom- 
fort and restrict the chest movements less than the apron, besides 
affording more definite support. Other forms of chest piece are in 
use. A simple one can be made over a plaster cast of the chest by 
shaping leather which is afterward stiffened by treatment with hot wax. 
This may be extended upward to support the chin in cases of high dor- 
sal disease. To this hard leather, steel buckles may be attached. 

The brace should be worn day and night, and removed daily that 
the back may be bathed. While the brace is off, the patient should lie 
on the face or the back. On no account should he sit erect. The 
back, after being washed, should be rubbed with alcohol and then pow- 
dered with face powder, corn starch, or Pears' fuller's earth. The 
brace should then be applied and buckled tightly into place. 

Chafing of the back is sometimes unavoidable in summer. When a 
severe chafed spot forms, the brace must be removed for the time and 
the child should lie flat in bed until the ulcer heals. A smooth cover- 
ing of leather is least irritating to the skin. The brace may be worn 
over a cloth or undervest, but is least likely to chafe if applied directly 
over the skin. 

Dr. Judson formulates a general rule which may serve as a guide in 



TUBERCULOUS DISEASE OE THE SPINE. 



n 



the treatment of Pott's disease by rigid apparatus, especially in all 
forms of the antero-posterior support. The rule reads: "The appara- 
tus may be considered as having reached the limit of its efficiency if it 
makes the greatest possible pressure on the projection compatible with 
the comfort and integrity of the skin." 

Certain braces have a tendency to " ride-up," and the neck pieces, 
instead of lying closely to the shoulders, project upward in a most un- 
sightly way. In general, this does not occur in braces which fit accu- 




/ 



«k 






to 




FlG. 76.— Taylor Back Brace with Oval 
Ring. Head support applied. 



FlG. 77.— Antero-Posterior Brace with Bent 
W T ire Head Support. 



rately. Sometimes, however, it is most troublesome, and in these 
cases padded perineal straps can be added, which are attached to the 
apron in front and to the lower end of the brace behind. They are, 
however, a source of much annoyance to children, in urination espe- 
cially, and are to be avoided if possible. The apron will sometimes be 
found to cut over the anterior superior spines of the ilium and also 
under the arms, and must be properly padded. 

In applying the brace the patient should lie upon his face, and the 
apron be spread under him. The brace should then be placed in posi- 



74 ORTHOPEDIC SURGERY. 

tion upon the bare back, or upon a thin, smooth cloth without wrinkles, 
and the apron strapped to it as tightly as is possible. The more tightly 
the two are strapped together, the more thorough is the fixation. The 
position of the straps and their number will vary in cases according to 
the situation of the disease, etc. The brace must, of course, if it is to 
exert pressure, always be straighter than the spine. 

A troublesome complication in the use of the anteroposterior 
brace is the presence of a lateral curve in the vertebral column ; this 
has been mentioned as an occasional complication of Pott's disease. 
The brace fits when the child lies down, but when he sits up the col- 
umn leans to one side again, and it is of course impossible for the brace 
to fit as before. Fortunately, this symptom passes slowly away as effi- 
cient support is afforded to the column, and then the brace fits again. 
Meantime it is best to apply the brace, bending up one neckpiece and 
bending the other down to make the top of the brace set squarely, or to 
apply a plaster jacket, which is ordinarily the most available mode of 
treatment under these conditions ; it is also best to keep the patient 
in a recumbent position as much as possible until the deformity im- 
proves. 

The application of the therapeutic principle of fixation in the best 
possible position varies according as the disease involves the upper, 
middle, or lower parts of the spinal column. 

Head Supports. — In the upper region, as elsewhere, it is desirable 
to prevent the weight of the head from falling upon the diseased bodies 
of the vertebrae. 

An efficient arrangement is one devised by Dr. Taylor, of New 
York (Chapter XXI., 5); an ovoid steel ring passes around the neck, 
made so that it can open, and be secured when closed, and arranged so 
that it can serve as a rest for the chin, and so that pressure can also be 
exerted on the occiput. This collar has at the front a hard-rubber chin 
piece accurately shaped to the chin, and may have at the back a stiff 
piece of sole leather projecting up from the back of the ring. This 
steadies the head and prevents the pressure of the occiput against the 
back of the headpiece. This collar at the back plays on a pivot, allow- 
ing lateral motion of the head. The pivot is attached to the usual back 
brace, and can be raised or lowered, as it is desired to increase or di- 
minish the upward pressure on the head. This appliance requires care 
and skill in application, and is useless unless properly fitted. 

Other forms of head support have been tried from time to time. 
Some of them have been useful (Chapter XXI., 6). 

A head support, devised by Goldthwait, affords good fixation. Its 
construction is evident from the figure, and it is serviceable in cases in 
which there is excessive sensitiveness of the spine, due to cervical or 
very high dorsal disease. The quadrilateral back brace devised by 



TUBERCULOUS DISEASE OF THE SPINE. 



75 



Dane l furnishes a useful form of support in Pott's disease (Chapter 
XXI, 8). 

Collars of various sorts, unattached to any other appliance, have 
been used, which, pressing on the chin and occiput above, and on the 
clavicles, sternum, and shoulders below, transfer the weight in part 
from the intermediate cervical vertebrae and check the forward bending 
of the cervical region. These collars can be made of plaster of Paris, 
but are cumbersome and unsightly. The most easilv made collar is 
that invented by the late H. 
O. Thomas, of Liverpool 
(Chapter XXI., 7). Leather 
stuffed with sawdust is the 
most available material of 
which to make them. They 
may also be made of tin, 
silicate of potash, wire net- 
ting, cardboard doubled and 



Fig 





Thomas Leather Collar. 



Fig. 79.— Leather Jacket with Head Support. 



padded, or any of the other materials mentioned in speaking of 
corsets. 

A convenient way of making these collars is by taking a piece of 
stout webbing, long enough to go loosely around the neck, and wind- 
ing it with sheet wadding or oakum until it is padded sufficiently. 
Then it should be covered with a bandage outside, and the ends of the 
webbing should be buckled together. The patient wears the collar a 
few days, and then as the padding becomes matted down, new padding 
1 Pediatrics, vol. x., i., 1900. 



7 6 



ORTHOPEDIC SURGERY. 



is added until the collar is the desired size and shape. It is then sent 
to a harnessmaker to be covered with leather. In this way a much 
more satisfactory result is obtained than by sending measures to a har- 
nessmaker in the first place. 

In all forms of head supports, if worn for a long time, a certain 
amount of recession of the chin takes place. The nature of this is not 
clearly understood, but the growth of the lower jaw is in a measure 
temporarily interfered with, and the front teeth in the lower jaw in 
severe cases do not articulate with those of the upper. The distortion 
results from the continued use of any form of head support, and is 

more liable to occur the more 
efficient the support. The jaw 
gradually resumes its shape 
after removal of the head sup- 
port. 

Collars, however, lack in 
steadiness, and, in order to se- 
cure accurate fixation of the 
head, they should be connected 
with uprights which extend be- 
low and are attached to the 
trunk. They are adapted only 
to the treatment of cervical dis- 
ease cf a character not very 
acute. When torticollis is pres- 
ent as the result of irritation, 
treatment by recumbency is 
advisable. 

It is hard to say just when 
the need for a head support be- 
gins. In general, if the disease 
is above the sixth dorsal verte- 
bra, a headpiece is indicated. Sometimes, if the disease is lower down, 
pain or distortion makes it evident that a head support is needed there 
also, or it may be necessary to add one if the brace does not make satis- 
factory pressure at the seat of deformity. 

Selection of a Method of Treatment. 

In the selection of mechanical supports the choice will lie between 
some of the fixed corsets of plaster of Paris (or the variations of that 
form of corset fixation) and the antero-posterior supports of steel. 

When careful and skilled attention can be applied to the construc- 
tion, attention, and needed alteration of a brace, it will be found of 
great efficiency in the treatment of Pott's disease in the convalescent 




FIG. 80.— Collar and Chest Piece for Cervical Pott's 
Disease. 



TUBERCULOUS DISEASE OF THE SPINE. 



77 



stage. It should be remembered, as has been shown, that it is impossi- 
ble to pry the vertebrae apart by leverage, as no apparatus could be 
worn which would sustain absolutely the weight of the upper part of 
the trunk from falling forward. The antero-posterior support is to be 
regarded as an apparatus which modifies rather than relieves interver- 
tebral pressure by the principle of leverage. 

The chief objection to the use of mechanical appliances as a method 
of treatment is that care and special skill are required, not only in the 
application of braces, but in the inspection and management of the cases. 

If the trunk is not thoroughly fixed by the straps, etc., of the ap- 
pliance, the brace becomes simply a splint of steel laid upon the back, 
and not a therapeutic agent. 

Rectification of the Deformity (Forcible Correction). 

Forcible correction of the deformity, with or without anaesthesia, is 
a method revived in recent times by Chipault, of Paris, although ordina- 





Fig. 81.— Pott's Disease before Correction. 
(Goldthwait.) 



Fig. 82. — Same Case Twelve Weeks after Cor- 
rection. (Goldthwait.) 



rily identified with the name of Calot, of Berck-sur-Mer. The latter 
demonstrated that under an anaesthetic a recent deformity, even of 
large size, may be partially or wholly corrected. Although it was 
shown that this is not a proceeding attended with as great risk to life, 
either near or remote, as would have been supposed, many casualties of 
various sorts have been reported. 



78 ORTHOPEDIC SURGERY. 

Hemorrhage, rupture of the pleura, rupture of abscesses, and frac- 
ture of the spine as well as paralyses are among the results reported, 
following injudicious application of the method. 

In 610 cases 1 reported by various operators, 21 deaths occurred, 
which is sufficient evidence against the employment of great force. 

It is obvious from the inspection of any series of pathological speci- 
mens of cured cases of Pott's disease that the diseased tissue is replaced 
by sound bony tissue to hold the disabled column, if time enough is 
given and if the process of repair has not been overwhelmed by the 
process of destruction. Where much force is needed to correct the 
deformity, the products of cicatrization will be torn or injured in the 
procedure. This, if extensive, is manifestly to be avoided. 

But although the correction of deformity by the use of violence is 
irrational and may be seriously injurious, the employment of moderate 
force in correction is frequently beneficial. When ankylosis and cica- 
tricial changes have taken place in the shape of the vertebral bodies, 
the surgical indications are to be content with the established cure, 
without incurring the risk of kindling the tuberculous ostitis by violence. 
In the majority of recent cases, especially in children, this condition of 
cicatrization has not been reached, as years are usually necessary before 
a cure is accomplished, and in these the kyphosis can generally be made 
straighter by the use of comparatively moderate force without the need 
of an anaesthetic. 

The mechanical means for rectification are those already mentioned 
as of use in the application of plaster jackets. Rectification judiciously 
applied is beneficial in all active cases of Pott's disease. Pressure 
symptoms will be relieved and in some instances paralysis checked. 

In older cicatrized cases great judgment is necessary in the employ- 
ment of correcting force. 

It must also be understood that after correction a relapse of the 
curve will take place unless the corrected position is maintained by 
adequate fixed appliances until the spine is well cicatrized in the cor- 
rected position. 

Operations on the Diseased Vertebrae. 

Operative measures are necessary under exceptional circumstances 
for the direct examination of the diseased vertebral bodies and the re- 
moval or drainage of the diseased bone. It must be remembered that 
in any event the vertebral bodies are more or less inaccessible, and that 
such operations are not likely to prove of benefit as routine measures. 

In the cervical region the anterior surfaces of the bodies of the ver- 

1 E. H. Bradford and Vose, giving bibliography: Trans. Am. Surgical Assn., 
1899 —Bradford and Cotton : Boston Med. and Surgical Journal, September 20th, 
1900. 



TUBERCULOUS DISEASE OF THE SPINE. 79 

tebrse may be reached either through the mouth, by a lateral incision, 
or by incision in the back of the neck. Through the mouth the oper- 
ating space is small, the proceeding difficult on account of the anaes- 
thetic, and the dangers of infection are evident. This method makes 
accessible only the second, third, and fourth vertebral bodies. The 
lateral method is preferable. An incision is made along the posterior 
border of the sternomastoid muscle ; the sternomastoid and omohyoid 
are raised and the space made by the splenius and omohyoid is 
reached. The dissection is carried through the longus colli, and the 
vertebral arteries are avoided. 

In the dorsal region exploration may be advisable in case an abscess 
in the posterior mediastinum is suspected. In such cases the operation 
of costo-transversectomy should be done. An incision at the side of the 
spinous processes uncovers the tops of the transverse processes and the 
bases of the ribs. The ribs are divided at the tuberosities and, with 
the transverse processes, removed. The spine is then reached by the 
finger. 

In the lumbar region an incision is made from the twelfth rib to the 
ilium, two and one-half inches outside of the median line ; the incision 
reaches to the border of the quadratus lumborum and the tips of the 
transverse processes should be felt. The dissection is carried down to 
the psoas muscle ; some of the fibres of this muscle are detached with 
care from one transverse process. The finger introduced reaches with- 
out difficulty the anterior surface of the vertebral bodies. The finger 
can strip up the psoas muscle through this incision and explore the 
vertebral bodies. The vertebral canal should not be opened. 

Treatment of Abscess. 

Abscesses may be treated by expectancy or by operation. 

(1) Expectancy. — Under proper treatment early abscesses may 
subside and be absorbed without detriment to the patient. 

Recumbency under the best mechanical conditions, preferably in 
the open air day and night, will favor the tendency to absorption. 
Aspiration will diminish the size of an abscess, but if it does not tend 
to absorb under the conditions mentioned, and especially if it shows a 
tendency to increase, it is better not to temporize, but to incise. The 
injection of abscess cavities with germicidal solutions should be re- 
garded as imperfect and not meeting the surgical indication of drain- 
age. 

(2) Operation. — When abscesses increase rapidly, or for any reason 
seem an injury to the patient, incision is to be considered. 

Incision of an abscess should be made under thorough aseptic pre- 
cautions, and as complete drainage as possible secured ; but it must be 
remembered that owing to the depth of the origin of abscesses in Pott's 



80 ORTHOPEDIC SURGERY. 

disease perfect drainage is not always as easily furnished as in more 
superficial abscesses. It is therefore desirable, especially in adults, to 
delay incision longer than would otherwise be surgically indicated. It 
is also to be remembered that as the focus of the disease has not been 
reached, a discharging sinus will persist and will ultimately become in- 
fected with pyogenic organisms, thereby adding a pyogenic to a tuber- 
culous infection. 1 

In retropharyngeal and cervical abscesses, however, drainage can 
ordinarily be readily secured. In dorsal abscesses an incision in the 
back is frequently sufficient ; but in some instances it will be necessary 
to perform costo-transversectomy to secure perfect drainage. In lum- 
bar and iliac abscesses it may be necessary, owing to the depth of their 
origin, to incise both in front and behind, which can be done with care 
without opening the peritoneal cavity. 

The above-mentioned facts must be borne in mind in advocating 
operation when it is not indicated by pressure effects and the distention 
of the abscess. 

Psoas abscess may be opened in the loin or in the iliac fossa, or in 
both places. Drainage may be made with a strip of gauze or a rubber 
tube and the dressing kept sterile as long as possible. After incision 
curettage is not desirable, as it is impossible to remove all of the dis- 
eased material and unnecessary traumatism is to be avoided. Flushing 
with sterile hot water is all that is required. It must be remembered 
that communication in front of the vertebral column may exist between 
the psoas sheath of one side and that of the other. 

A retropharyngeal abscess is best opened by passing into the mouth 
a bistoury wound to within half an inch of its point with cotton, and 
cutting freely, using the finger as a guide. The child should be held 
face downward in order that the pus may not enter the trachea, and 
plenty of swabs should be at hand to keep the mouth clear, for the 
gush of pus is sometimes considerable. Such abscesses may also be 
opened by lateral incisions from the outside. 

Abscess in the mediastinum is opened as described above in speak- 
ing of costo-transversectomy. 

Other abscesses are opened on general surgical principles. 

Treatment of Psoas Contraction. — When flexion of one or both 
thighs has come on it is not likely to diminish spontaneously, and if 
the condition is allowed to go untreated, such contractions may become 
permanent. 

A permanent contraction of one or both psoas muscles with the 
thigh flexed is a serious deformity. If it exists on both sides, the pa- 
tient can walk only with the trunk held nearly horizontal. If it is uni- 
lateral, it leads to a very serious disability, requiring in most cases the 
1 Schuckhardt and Krause : " Die Tub. der Knochen und Gelenke." 



TUBERCULOUS DISEASE OF THE SPINE. 81 

use of a crutch, for the diseased spine cannot be flexed to allow the foot 
to reach the ground in walking as it does when flexion of the thigh 
exists as a result of hip disease. For these reasons it is desirable to 
attack psoas contraction with very vigorous measures, which afford a 
prospect of averting any permanent, contraction. 

In the early stages the child should be put to bed on a frame. A 
light extension should be applied to the leg with pulley extension, and 
the pulley should be gradually lowered until the leg is straight and the 
flexion overcome. In cases in which the flexion has existed only 
a few weeks or months, this is generally easily accomplished in two 
or three weeks. If not, or if a more rapid method is desired in the first 
instance, the child should be anaesthetized and the leg straightened 
by force and retained by plaster of Paris. If this cannot be done 
with the use of moderate force, it is better to divide and cut the 
fascia and the contracted bands— an operation which cannot often be 
done thoroughly subcutaneously, for there are many deep bands. 

The deformity is almost sure to return if the patients are allowed to 
go about, and they should either be kept on a frame or an arm should 
be extended down from the brace or the jacket to keep the thigh fully 
extended. Finally, subtrochanteric osteotomy of the femur may be 
necessary in severe cases, but it should not be done until after recovery 
from the Pott's disease. 

Treatment of Paralysis. 

When paralysis is threatened, the patient should be put to bed on a 
frame so padded as to press upon the deformity arid hold the vertebrae 
somewhat separated. In dorsal cases traction may be added. An 
attack may thus be averted. 

When paralysis is present, a plaster jacket should be applied in 
strong hyperextension of the spine at the seat of the deformity (by one 
of the methods mentioned), and the patient should be kept recumbent 
until the paralysis begins to disappear. 

The tendency of the paralysis is strongly toward recovery under 
favorable conditions of treatment. Taylor and Lovett found, in forty- 
seven cases in private practice, eighty-three per cent of recoveries. 
The average duration of the cases was one year, but when the paralysis 
came under treatment the average was only seven months. Relapses 
occur at times, and although the loss of sensation and paralysis of the 
sphincters are symptoms pointing to a serious involvement of the cord, 
recovery may follow. 

These considerations bear strongly on the question of operative 
treatment for paralytic cases. 

Drugs are of little or no value, and it is not possible to attach much 
importance to the use of the cautery or of counterirritants. 
6 



82 ORTHOPEDIC SURGERY. 

Laminectomy. — A spicule of bone or an intraspinal abscess may be 
the source of pressure at any stage of the disease, and in such cases, 
of course, operation is demanded. In cases of long standing in which 
the paralysis has become very extensive and has involved sensation, 
and possibly the sphincters of the bladder and rectum, the question 
arises as to whether the operation is likely to be of benefit or whether 
the damage to the cord is not already irreparable. 

The operation consists in cutting down upon the spinous processes 
in the region of the deformity, the incision being slightly to one side of 
the centre, so that the resulting cicatrix will not be unduly pressed 
upon during recumbency. All the soft tissues are then stripped with 
a periosteal knife, until the laminae are exposed. The spinous processes 
are then removed with bone forceps over the affected area. Laminec- 
tomy forceps are then used to cut away all of the laminae covering the 
cord at the seat of pressure. The dura may or may not be opened. 
A probe is then passed up and down the spinal canal, to be sure that 
all pressure is removed, and the wound is dressed. The patient should 
be laid on the face after operation if it is more comfortable. 

It may be said that resection of the laminae of the vertebral column 
is an operation which is not gaining in favor. The death rate is high 
(36.44 per cent), and with the more efficient treatment of paralysis by 
mechanical means laminectomy must be reserved for the gravest cases 
which show no sign of improvement after a faithful and long-continued 
trial of the ordinary measures. But at the same time brilliant suc- 
cesses at times follow the operation, so that it holds out the hope of 
relieving cases of paraplegia which would otherwise have been hope- 
less. The operation, however, has no place in the treatment of Pott's 
disease until the conservative measures have been faithfully tried over 
a sufficient period of time— measures which in most cases will prove 
efficient and successful in the relief of the paralysis. Immediate im- 
provement is not necessarily to be expected. 

SUMMARY OF TREATMENT. 

The proper treatment of Pott's disease is not the application of any 
method, the use of any corset or brace, but the employment of such 
means as are most efficient for carrying out the object aimed at. A 
brace is useless in the case of persons unable to adjust it; a plaster 
jacket applied about the trunk is useless in disease of the cervical or 
high dorsal region. Recumbency, carried to a point of depressing the 
patient's mental and physical condition, is as much of a mistake as 
to drag a patient about who is anxious to lie down. 

In the treatment of these cases, the surgeon should be familiar with 
the advantages to be gained by all methods, and should employ each 



TUBERCULOUS DISEASE OF THE SPINE. 83 

as the case may demand, and for such a length of time as the circum- 
stances of the case may require, or combine the different methods as 
may be advisable. 

In a general way he may formulate to himself that : in acute, painful 
cases absolute recumbency with proper fixation is the best method until 
the active stage of the disease is passed ; in middle and lower dorsal 
Pott's disease an immovable plaster jacket, without head attachment, 
in the case of negligent persons, is most available. 

Whether recumbency for a time is required, or whether ambula- 
tory treatment with fixation appliances is sufficient, are questions of 
judgment in individual cases. 

A choice between plaster jackets and steel appliances is a choice 
between a fixed and a movable support. The former is better in the 
more acute forms of the disease. The latter requires constant and 
faithful attention to guard against imperfect or loose application and in- 
adequate support. 

Apparatus carefully adjusted and applied is evidently preferable to 
removable plaster and other corsets, being less clumsy, but apparatus 
properly made is both more expensive and demands more skill and time 
on the part of the surgeon. 

In cases of Pott's disease the treatment involves much responsibility 
and cannot be left to a mechanician unfamiliar with the pathological 
conditions, as is sometimes done. The surgeon should familiarize him- 
self with every detail and be responsible for this as well as for the gen- 
eral treatment. 



CHAPTER III. 
TUBERCULOUS DISEASE OF THE HIP. 

Definition. — Pathology. — Clinical history. — Diagnosis. — Differential diagnosis. — 
Prognosis. — Treatment (mechanical— operative). 

The affection which is commonly known as hip disease is the most 
frequent affection of the hip-joint, and by common usage the general 
name of "hip disease" or "hip-joint disease" has become limited to 
that especial affection of the joint which comes now for consideration. 
It is known also by the names of morbus coxarius or morbus coxae, 
coxalgia, coxitis, chronic articular ostitis of the hip, and coxo-tubercu- 
lose (Lannelongue). The pathological condition commonly found is a 
chronic tuberculous ostitis of the epiphysis of the head of the femur or 
of the acetabulum. 

PATHOLOGY. 

The pathology of hip disease in general does not differ from that of 
tuberculous disease of bone which has already been referred to. 

The head of the femur is the primary seat of disease, 1 in a majority 
of the cases the epiphysis or juxto-epiphyseal region being the part at- 
tacked. In about twenty-five per cent of the cases the primary focus 
is in the acetabulum. 

When once the acetabulum has become diseased either primarily or 
secondarily, enlargement of it is apt to take place. The irritated pelvic 
femoral muscles which are in a state of tonic contraction crowd the 
head of the femur against the upper and back border of the acetabulum ; 
under this continual pressure absorption of that portion of the rim of 
the acetabular cavity takes place with an actual enlargement of the cav- 
ity from below upward. This so-called migration of the acetabulum is 
one cause of shortening of the limb, and measurement will show that 
the trochanter lies above Nelaton's line. 

The changes in the head of the femur are chiefly the result of ostitis 
and pressure. There may be alteration in the shape of the head of the 
bone, if it is worn away by the pressure induced by constant muscular 
spasm with destruction of the articular surface. 

'Konig: Deutsch. Zeit. f. Chir., xi., 1879. — Konig: "Die spec. Tuberc. der 
Knochen und Gelenke," Pt. II., Berlin, 1903. — G. A. Wright: " Hip. Dis. in Child- 
hood," p. 17.— Habern: Cent. f. Chir., April 2d, 1SS1. — E. H. Nichols: Orth. 
Trans , vol. xi., p. 353. 

84 



TUBERCULOUS DISEASE OF THE HIP. 



85 



" Dislocation " of the hip in hip disease is a term often used which 
is perhaps misleading. Partial destruction of the softened head of the 
femur in the manner just described may lead to a shortening of the 
limb and to an elevation of the trochanter above its proper level. The 
wearing away of the acetabulum produces the same result ; but true 
dislocation is rare, because, even if the head of the bone is almost en- 




FlG. 83.— Frontal Section through a Normal Right Hip Joint in an Adult. 

tirely destroyed, there is so much inflammatory tissue deposited about 
the joint that the head of the bone is retained partly in place. 

Fracture of the atrophied and degenerated shaft of the femur may 
occur in occasional cases. Separation of the head of the femur at the 
epiphyseal line is less uncommon. 

A typical specimen from a fairly advanced case of hip disease shows 
a reddened and thickened synovial membrane, often with granulations ; 
the cartilage is gone from the head of the femur or hangs in tags or 
shreds, and the general appearance of the end is often spoken of as 



86 



ORTHOPEDIC SURGERY. 



"worm-eaten"; sometimes the whole cartilage may be lifted from the 
bone by a layer of granulations. The epiphyseal portion of the head of 
the femur has disappeared in part or altogether, and a ragged, carious 
end of bone will articulate with an acetabulum covered with fungous 
granulation in part or wholly replacing cartilage. 

The whole epiphysis may form one sequestrum, but this is not com- 
mon in tuberculous ostitis, though not as rare in infectious ostitis. 




Fig. 84.— Erosion of the Upper Part of the Acetabulum. (Warren Museum.) 

Perforation of the floor of the acetabulum may take place. Inside 
of the pelvis a dense wall of fibrous tissue and thickened periosteum 
shuts off the head of the femur or the contents of the joint from the 
pelvic cavity. In cases in which the disease has gone on as far as this, 
disease of the pelvic bones may coexist. In the other direction, when 
once the disease of the femur has passed the epiphyseal line, there is no 
limit to be set to its course or its extent of destruction. 

Abscesses appear externally if the disease of the joint extends to 
the periarticular tissues or when a separate focus of disease forms out- 



TUBERCULOUS DISEASE OF THE HIP. 



87 



side of the joint and spreads to the surrounding soft parts. Suppura- 
tion inside of the pelvis is not a very uncommon condition in the ace- 




FlG. 



•Focus in Head of Femur. 



tabular form of the disease; in the femoral form it accompanies only 
advanced disease. 

A natural cure results in one of two ways : by the absorption or cal- 



JJH§F 


S. JP*mi m-iM 







Fig. 



-Separation of the Head of the Femur at the Epiphyseal Line. 



cification of the tuberculous tissue at an early or a late stage of the dis- 
ease ; or by the purulent degeneration of such tissue and its evacuation 
and discharge by an external opening. The suppuration which comes 






88 



ORTHOPEDIC SURGERY. 



later seems to be nature's effort to eliminate the diseased material, and 
it is the common method by which spontaneous cure results when it 
does occur. This late stage of the disease is characterized by malposi- 
tions and shortening of the limb and much impairment of the general 
condition in most cases. It is this state of affairs that makes the spon- 
taneous cure of hip disease undesirable and imperfect. When sponta- 
neous cure does occur it is usually 
with an ankylosed joint. 

In these cases, however, one 
sometimes finds at autopsy an in- 
cluded cheesy focus which still pre- 
sents some signs of activity. It is 
to these foci that one looks for an 
explanation of the late relapses of 
the disease and the very great harm 




FlG. 87.- Hip. Excised head of femur. Artic- 
ular cartilage turned up at one side shows 
tuberculous bone beneath. Primary focus 
was in acetabulum, a, Head of femur, 
surface tubercles ; b, elevated cartilage. 
(Nichols.) 




Fig. 88.— Acetabulum Seen from Outside. 
a, Tuberculous granulations; &, tubercu- 
lous cavity. (Nichols.) 



which is sometimes done by forcible manipulation of these joints and 
consequent lighting up of the original tuberculous disease. 1 



CLINICAL HISTORY. 

Early Symptoms. — The beginning of the affection is most often 
gradual and insidious, but at times it begins so abruptly, according to 
the parents' account, as to suggest a traumatic origin. The child will 
be noticed to limp at times with intervals of comparative freedom from 
lameness. This lameness increases, and it will be found that the patient 
is inclined to strike the ball of the foot rather than the heel in walking ; 
although the heel can be put down to the floor, yet instinctively the 
knee is slightly bent and the heel raised when the weight of the trunk 
falls on the hip. There is a certain amount of stiffness of gait apparent 
in the morning when the patient first gets out of bed, and after sitting 

1 Trans. American Orthopedic Association, vol. i. 



TUBERCULOUS DISEASE OE THE HIP. 89 

for a while ; this passes away after the patient has walked or played 
about. At night, as a rale, the limp is less than in the morning. The 
limp can perhaps best be described as a very slight stiffness and a dis- 
inclination to bear prolonged weight upon the affected limb. 

If the child be inspected it will be seen that in standing the knee of 
the affected side is often flexed slightly, the pelvis being tipped and 
the thigh slightly abducted. The tilting of the pelvis and abduction 
of the thigh may be so slight that it is scarcely noticeable, except by 




Fig. 89.— Head of Femur Eroded, Partly Destroyed, Partly Dislocated. Fibrous ankylosis. 
a, Head of femur; b, eroded head of femur; c, ankylosis; d, acetabulum. (Nichols.) 



the deviation from the median line of the fold between the two but- 
tocks. In girls the vulva on the affected side may be lower than on the 
other side. 

Pain at this stage is very often absent, and if present is noted as 
night cries, to which allusion will be made. 

Course of Disease. — It has been customary to divide hip disease into 
stages and to ascribe to these stages certain definite symptoms. Neither 
from a clinical nor a pathological standpoint is it desirable to attempt 
any such division. 

In the early part of the disease pain at night, stiffness, and limping 



go 



ORTHOPEDIC SURGERY 



are the chief symptoms. Then follow malpositions of the limb, more 
severe disability, and perhaps greater pain and sensitiveness. 

Succeeding the deformities which have just been described, one 
may find abscess formation and the development of sinuses ; and this 

stage of the affection will 
hardly have been reached 
without considerable con- 
stitutional deterioration, 
which may become severe. 
Lameness. — From be- 
ing at first scarcely per- 
ceptible, the lameness 
increases and the limp 
becomes very noticeable. 
In very acute cases pain 
may become so severe that 
the child will refuse to 
use the leg, or malposition 
of the leg may come on 
rapidly and the limp may 
on that account become 
excessive; but in general 
the child walks without 
pain, though perhaps limp- 
ing badly. Until the late 
stages of the disease lame- 
ness is not due to bone 
shortening. 

Pain. — As the affec- 
tion progresses, pain in 
the knee and sensitiveness 
to jarring the limb may 
become prominent symp- 
toms. An unconscious 
protection of the joint may 
be noticed in the move- 
ment of the patient; the 
foot of the well limb may 
be placed under the lower 
part of the other leg when 
it is to be suddenly lifted by the patient, as from the floor to the bed, 
or from the bed to the floor, or in moving from one side of the bed to 
the other. 

In manipulating the leg at this stage pain may follow the slightest 




Fig. 90.— Hip-joint from Boy Nine Years Old. Hip dis- 
ease had existed six years previously and had been 
treated by traction. Death from meningitis. Speci- 
men shows no widening of acetabulum, and but little 
alteration in the head of the femur. 



TUBERCULOUS DISEASE OF THE HIP. 91 

jar to the joint, or, on the other hand, the joint may be perfectly stiff 
from muscular spasm and yet manipulation may be wholly painless. In 
other cases motion in a certain arc is possible without causing pain, but 
when the limits of this arc are reached, further motion becomes painful 
or is prevented by muscular fixation. The sensitiveness of the joint 
may become so great, when an acute stage supervenes, that the slight- 
est movement of the patient or jar of the bed or room causes extreme 
suffering. This stage may come suddenly and gradually pass away, the 
pain diminishing by degrees under the enforced treatment of rest, or it 
may be persistent. A characteristic position is frequently taken by the 
patient, who places the well foot on the dorsum of the foot of the 




Fig. 91. Fig. 92. 

FlG. 91. — Specimen from Excision of Hip when Traction has not been Employed. Severity 

and duration of disease similar to that of case in Fig. 92. 
Fig. 92.— Specimen from Excision of Hip Treated by Efficient Traction for Three Years. 

Operation done because of failure in general condition. 



affected limb, exerting pressure away from the acetabulum. Pain may 
be absent at any or all stages of the disease, and is not a diagnostic sign 
for or against the presence of J dp disease. Sensitiveness may be absent, 
upon which condition, however, at any time a sensitive condition of the 
joint may supervene. The pain is often remittent, and here, as in all 
the symptoms of this affection, marked remissions may occur. The 
location of the pain is variable, but is generally referred to the inside 
and front of the thigh near the knee or directly at the knee-joint. The 
intimate relations and anastomoses of the sciatic, obturator, and ante- 
rior crural nerves seem to furnish the best explanation of this. 

In a minority of cases the pain is referred to the joint itself. In 
the more acute cases sensitiveness to pressure on the trochanter and to 
deep pressure over the anterior surface of the joint (just below the 
anterior superior spine of the ilium) is present. 



9 2 



ORTHOPEDIC SURGERY. 



Night Cries. — At an early stage of the affection the symptoms of 
" night cries " often appear. They occur in the early part of the night 
usually, and may become an annoying symptom. After the patient is 
asleep, and to all appearances entirely unconscious, sleep will be inter- 
rupted by a cry as if of severe pain, followed by moaning or crying for 
a few seconds; the child being unconscious or only half-conscious of 
the cause of the pain. These do not often occur when the patient is 
entirely awake, and are caused by the spasmodic twitching of the mus- 
cles abnormally excitable from irritation, reflex to the inflammation of 
the joint. These cries may be repeated fifteen or twenty times during 
the night. They may be entirely wanting in the mildest cases. 

Muscular fixation (muscular spasm) is always present in some de- 
gree, restricting the joint's normal arc of motion. It is due to a reflex 
irritability of the muscles controlling the joint, which causes them to 




Fig. 93.— Instinctive Effort at 



'raction in Acute Disease of the Left Leg. 
Essay.) 



(Fisk Prize Fund 



maintain a condition of tonic spasm of greater or less degree. It dis- 
appears under full anaesthesia. Increased stiffness appearing in the 
course of treatment is a sign of inefficient treatment or of increase of 
the disease. This muscular rigidity is the most important sign of the 
disease, for not only is it the chief reliance in the matter of diagnosis, 
but it is the cause of the malpositions of the limb, of the wearing away 
of the acetabulum and of the head of the bone, and it lies at the root of 
much of the pain. It furnishes the most accurate index of the progress 
of the case, and improves or becomes worse as the case becomes better 
or worse. The importance of the recognition and accurate study of 
this symptom cannot be overestimated. 

If a child with severe hip disease be laid on his face and lifted by 
the legs with a view to determining the flexibility of the lumbar spine, 
one can often notice the lumbar muscles stand out like cords, and hold 
the lumbar spine quite rigid. This often gives rise to the suspicion of 
the coexistence of Pott's disease. This symptom is present only in the 
severer forms of hip disease. 



TUBERCULOUS DISEASE OF THE HIP. 



93 



Atrophy. — A marked atrophy of the muscles of the thigh, hip, and 
leg is characteristic. It is supposed to be reflex to the disease of the 
joint. 1 

Atrophy of the muscles controlling an inflamed joint begins early 
and may be very marked, even in simple acute synovitis. That this is 
something more than the mere atrophy of disuse is shown by the fact 
that it begins so sharply and so early, 
that it is greater in the diseased 
limb than in the well one even when 
the patient has been in bed from 



FSH 

. tea - ■ 


-i i 

'■ w 

'I" 

I 




Fig. 94.— Obliteration of Gluteal 
Fold in Hip Disease of Right Side. 



Fig. 95.— Position Assumed in Standing, 
with Slight Abduction of the Right Leg. 



the first, and that the muscles, although atrophied, are not soft and 
flabby, but tense. 

Diminished resistance to the passage of the „r-rays in the epiphyses 
of the hip, indicative of greater vascularity, may be seen in the earlier 
stages of hip disease. 2 

Increased patellar reflex is generally present in the affected leg dur- 

1 Emile Valtat : " L'Atrophie Muse, dans les Mai. Articulaires," Paris. 

2 Lovett and Brown: "The Diagnostic Value of the ;r-Ray in Hip Disease," 
Phila. Med Journ., Jan. 28th, 1905. 



94 



ORTHOPEDIC SURGERY. 



ing the early part of the disease and the thigh muscles show a dimin- 
ished contractility to the faradic current. 

Atrophy generally can be easily appreciated at an early stage of the 
disease by grasping the muscles in the hand or by measurement with a 
tape. The difference in the circumference of the two thighs will be 
perhaps one-quarter of an inch to an inch, and the difference in the size 
of the calves is generally about half of the thigh difference. In chil- 
dren who can use the leg fairly well there is rarely any calf atrophy at 
the first examination. The obliteration of the fold of the buttock on 
the affected side is a result partly of muscular atrophy and partly of the 
periarticular swelling which accompanies the disease. It is a common 
but not a constant symptom at the early stages of the disease. It is 
also partly due to the flexed attitude of the limb, which naturally di- 
minishes the prominence of the buttock on that side. 

Malpositions of the Limb. — The fixation of the diseased limb in a 
distorted position is one of the commonest incidents of the affection. 




Fig. 96.— Severe Abduction and Eversion in a very Acute Case. 

This is due to the tonic muscular contraction so often alluded to. 
These malpositions may hold the limb in flexion, adduction, abduction, 
or eversion, or in any combination of these; the cause which deter- 
mines the kind of malposition in an individual case cannot be formu- 
lated. Flexion of the thigh is chiefly due to the muscular contraction, 
which is constant in chronic disease of the joint, and partly to an un- 
conscious effort on the part of the patient to assume a position most 
comfortable for the joint and most protected from jar. 1 These deform- 
ities 2 generally disappear under treatment by rest or traction ; but again, 
they reappear in cases under treatment if treatment has not succeeded 
in checking the progress of the disease. They often accompany a sen- 
sitive condition of the joint, which may be the precursor of abscess. 
If the malposition is allowed to become permanent the final result 

1 Lannelongue : " Coxotuberculose," Paris, 1885. — Hilton : " Rest and Pain," 
London. 

' 2 H. M. Sherman: Orth. Trans., vol. xii. 



TUBERCULOUS DISEASE OF THE HIP. 



95 



can never be so good as when cicatrization takes place in a more nor- 
mal position. The limp in ankylosed limbs depends more upon the 
amount of flexion and adduction than on anything except perhaps the 
bone shortening. It is, therefore, of much importance to diminish in 
all cases the amount of malposition present. 

When adduction is present in both legs, as in double hip disease, 
and ankylosis of both hips has oc- 
curred, cross-legged progression 
may be necessary on account of the 
inability to separate the legs. 

The position in standing and ly- 
ing is modified by the occurrence of 
these malpositions; abduction or 
adduction causes tilting of the pelvis, 
and flexion causes a marked lordo- 
sis of the lumbar spine in standing 





Fig. 



97, 



-Adduction of the Left Leg in Acute 
Hip Disease. 



Fig. 98.— Case Showing Marked Flexion 
with Adduction of the Left Hip Joint. 



with the legs parallel ; by standing w r ith the diseased leg somewhat 
flexed the lordosis can be overcome. The same arching of the lumbar 
spine occurs when the patient lies on a table and the flexed leg is 
brought down. 

Periarticular Symptoms. — An important sign is found in the thick- 
ening over the anterior surface of the joint when palpated in the groin 
as contrasted with the other side. An indefinite oval thickened area 
is felt deep down. At other times the thickening is most marked at 



9 6 



ORTHOPEDIC SURGERY. 



the posterior aspect of the joint, behind the trochanter. This sign is 
an early one and of great value in the early recognition of the disease. 
A density in the superficial tissues over a diseased hip which the other 
side does not possess is often found at a comparatively early stage of 
the affection. Behind or in front of the trochanter the deep tissues are 
resistant and the fossa existing there is filled out, and the great tro- 
chanter feels enlarged and thicker than 
its fellow when grasped by the fingers 
deeply pressed in. 

The inguinal glands of the affected 
side are often enlarged and they may 
be so much distended that they ob- 
struct the venous return and the skin 
may be marbled with superficial veins. 
They are at times the seat of super- 
ficial abscesses. A gland lying on the 
iliac vessels is frequently found en- 
larged in hip disease and is palpated 
just above the ramus of the pubis. 
In very severe cases the upper part of 
the thigh and the tissues in the vicinity 
of the hip may become swollen gener- 
ally from an oedema of the periarticular 
tissues. This may disappear or be- 
come localized in the formation of an 
abscess. 

Abscess. — In a proportion of cases 
suppuration takes place. The site and 
course of the abscesses vary accord- 
ing to the seat and size of the original 
focus of the ostitis, whether in the 
femur or acetabulum. Abscesses may 
be entirely periarticular, if the initial 
lesion of the epiphysis extend in a 
course outside of the joint; or, as is 
commonly the case, they may come 
joint; or, having been periarticular, 




FIG. 99.— Left Hip Disease with Abscess 
on Outer Side of Thigh. 



from suppuration within the 
they may later involve the joint. 

The invasion of the abscess is frequently without constitutional dis- 
turbance ; exacerbation of pain and joint symptoms is, however, a fre- 
quent accompaniment of this formation. Abscesses may be absorbed 
or may evacuate themselves spontaneously either completely or par- 
tially, the residual fluid following along the course of the sheaths of the 
muscles and the fasciae, reappearing later as secondary abscesses, the 



TUBERCULOUS DISEASE OF THE HIP. 



97 



same abscess causing five or six fistulous openings. These openings 
discharge pus and serum for months and years in most cases. These 
sinuses after a short time become infected with pyogenic organisms. 
With the bursting of an abscess and the discharge of any considerable 
quantity of pus the patient's condition may show rapid improvement, 
or, if imperfect drainage takes place, reaccumulation of the pus may 
occur and the patient's condition may become worse. 

When the pus has left the joint it generally burrows between the 
thigh muscles to reach the skin, where it appears as a swelling of vary- 
ing size. Fluctuation is usually marked. As the abscess invades the 
skin the latter becomes thin and red, and ulcerates in one or two places, 
evacuating the abscess. The contents of the abscess may, however, in 
a few instances be absorbed even at a stage when fluctuation is marked, 
and the swelling may disappear, perhaps leaving a depression beneath 
the skin. 

The pus most commonly reaches the skin at the anterior border of 
the tensor vaginae femoris muscles ; it may, however, gravitate back- 
ward and open back of the great trochanter or at the lower border of 
the glutaeus maximus ; it may come around to the inner side of the 




FIG. ioo.— Deformity in Untreated Double Hip Disease. 

thigh and perhaps open in front of the adductor tendons or even dis- 
charge into the rectum ; finally, it may ascend the sheath of the psoas 
muscles and point above Poupart's ligament, or it may descend in the 
thigh muscles and point in the popliteal space. The seat of the primary 
disease cannot be inferred from the situation of the abscess. 

Abscess is very often the result of inefficient treatment and im- 
proper care. 1 

Shortening. — The effect of persistent muscular spasm of muscles 
about the hip-joint, characteristic of hip disease, is to crowd the femur 
1 Lovett and Goldthwait: Ortho. Trans., vol. ii., p. 82. 

7 



9 8 



ORTHOPEDIC SURGERY. 



against the acetabulum and to produce the enlargement of the acetabu- 
lum and the absorption of the head of the femur, with resulting shorten- 
ing of the limb. 

In addition to the shortening produced by absolute destruction of 
bone in the femur or the acetabulum, there is a decided trophic dis- 
turbance of the limb which results in retarding the bony growth and 
causes at the same time a certain amount of bone atrophy ; retarded 
growth of the affected limb becomes evident in the early months of the 
disease, and is a permanent condition which is not outgrown as years 

go on, for the affected limb 
always lags behind the other 
in its growth. 

The shortening may be even- 
ly distributed between the bones 
of the leg and those of the thigh, 
or it may be most marked in 
the bones of the leg. When 
there is much shortening of the 
leg, the foot of the affected side 
is also smaller than the other. 
The difference in the length of 
the legs almost always increases 
slightly after the disease is 
cured. 1 

General Condition. — Chil- 
dren with hip disease are often 
robust at the beginning of the 
affection and sometimes the 
general condition continues 
good, but these cases are excep- 
tional. More often the child is 
pale and the appetite fails at 
times; there is often loss of 
flesh ; in some mild cases and in most of the severe ones decided con- 
stitutional disturbance results. 

Remissions. — Any account of the symptoms of hip disease would be 
incomplete without speaking of the remissions in the course of the 
affection. In the early stage this is especially noticeable, and a patient 
may to outside appearances entirely recover from the symptoms of pain, 
lameness, and discomfort for some days or weeks. Then the symptoms 
return with increased vigor, perhaps to disappear again in a short time. 
The muscular stiffness does not wholly disappear at these times, 
although it may improve along with the other manifestations of the dis- 
1 Shaffer and Lovett : N. Y. Med. Jour., May 21st, 1887. 




FIG 101. — Position Necessitated by the Perma- 
nent Flexion Deformity Resulting from 
Double Hip Disease. 



TUBERCULOUS DISEASE OE THE HIP. 



99 



ease. The later course of the disease is marked by much greater uni- 
formity, but even then temporary improvement may be quite marked. 

Temperature. — Children with hip disease under treatment by ambu- 
latory measures have as a rule a higher afternoon temperature than 
normal. In 627 observations made on cases of hip disease and Pott's 
disease at the Out-Patient Department of the Children's Hospital a rise 
of temperature of one or two degrees was common. Ninety per cent 
of all cases, acute or chronic, mild or severe, had an evening tempera- 
ture of at least 99 , and a rise to 103 or 104 in severe cases was not 
necessarily an indication of ab- 
scess. 

Double Hip Disease. — The dis- 
ease seldom begins in both hip- 
joints at the same time, and the 
second joint may become inflamed 
while the patient is under treat- 
ment in bed for the first joint, 

The course of double hip dis- 
ease would appear to vary some- 
what from that of single hip dis- 
ease. It is, as a rule, of a severe 
type and tends strongly to anky- 
losis. The amount of pain suf- 
fered in the joint last affected is 
usually less than that of the first 
joint, probably because there is 
less jar or motion when two hip- 
joints are affected than when one 
alone is attacked. 

Malpositions are more than usually troublesome and may be differ- 
ent in the two hips. Recovery without deformity and with as much 
motion as possible is most important in double hip disease. 

DIAGNOSIS. 

The diagnosis of hip disease may be easy or difficult ; ' in the earli- 
est stages errors in it are sometimes made, and care is necessary for a 
positive diagnosis in any stage. The most common error is the belief 
that the presence of pain or tenderness is necessarily present in hip 
disease, and that its absence excludes the possibility of hip disease. 
Another error often made is to look for "grating" in the joint as a 
sign of the disease. That sign is to be obtained only by the use of an 
anaesthetic, by which means the muscles guarding the joint are re- 

1 R. W. Lovett: " The Diagnosis of Hip Disease." Boston Med. and Surg. 
Journ., August 14th, 1902. 




Fig. 102. 



-Progression in a Case of Severe 
Double Hip Disease. 



IOO 



ORTHOPEDIC SURGERY. 



laxed, and then only in advanced cases when two bony and eroded sur- 
faces lie in contact. 

The diagnostic symptoms in hip disease which should be borne in 
mind in making a diagnosis of hip disease are as follows: 

i. Muscular spasm (stiffness of the joint or limitation of its motion). 

2. Lameness. 

3. Attitude of the limb in standing, walking, or lying (adduction 
flexion and abduction of the limb), and shortening. 

4. Atrophy. 

5. Swelling. 

These symptoms vary in prominence at different stages of the dis- 
ease. 

It may be said that the early diagnosis must be made chiefly by the 
symptom of muscular rigidity and by palpation of the joint. The ab- 




FlG. 103. — Method of Examining the Hip. 



sence of pain or sensitiveness counts for nothing and atrophy is not 
significant of anything more than inflammation of the joint. The limp 
is peculiar, but a similar one is present in other conditions. 

I. Muscular Spasm.— The chief diagnostic sign in hip disease, upon 
which the main reliance must always be placed, is the presence of stiff- 
ness of the joint or limitation of its proper arc of motion when the limb 
is passively manipulated. Except in the very earliest stages there can 
be no hip disease without a perceptible limitation of motion, unless the 
focus of disease is remote from the joint. This limitation of motion is 



TUBERCULOUS DISEASE OE THE HIP. 



101 



not the result of adhesions or beginning ankylosis in early hip disease, 
but it is the result of a tonic contraction of the muscles controlling the 
joint, and disappears under anaesthesia in the early stages of the disease. 
In the detection of this most important diagnostic sign it should be 
borne in mind that some care is required to discover slight limitation of 
motion in very young children, who are apt to resist thorough examina- 
tion. The voluntary resistance to manipulation due to fright is, how- 
ever, always resistance to all motions of the limb ; if by slight force this 




FIG. 104.— Method of Determining- the Limitation of Extension in Hip Disease. 

is overcome, resistance to any especial motion will not be encountered 
unless hip disease is present. A comparison of the resistance of one 
leg with that of the other will reveal abnormal resistance. The normal 
amount of abduction is, however, slight, and resistance to motion in this 
direction, therefore, is an early test of importance. Extreme abduction 




Fig. 



105.— Lordosis Resulting- from Bringing the Flexed Leg in Hip Disease Parallel to the 

Other. 



and rotation of the thigh flexed at right angles to the body are tests 
likely to reveal the smallest degree of limited motion. 



In 



youm 



and frightened children the tests for limitation of motion 



at the hip-joint are best made with the children lying on the mother's 
lap or leaning on the mother's shoulder. In examining older children 
for muscular stiffness, the clothes should be removed and the patients 
should lie upon a hard surface rather than on a bed. Attempts to 



102 ORTHOPEDIC SURGERY. 

move the limb should be made gradually, gently, and persistently — 
rough force only exciting resistance and making a delicate examination 
impossible. It is advisable first to put the normal leg through the same 
manipulations which are to be made on the affected side. The most 
convenient order of motion in examination is first flexion, then abduc- 
tion and abducting rotation with the thigh flexed, then extension. The 
suspected limb should be held at the ankle or knee with one hand, while 
the other hand will grasp the pelvis to ascertain when motion in the 
joint ceases and movement of the pelvis begins. Examination under 
anaesthesia shows less than the examination mentioned, at the early 
stage of hip disease, as muscular spasm, the most important diagnostic 
sign, has been overcome and is absent. 

If the limb is extended so that the popliteal space be placed upon 
the hard surface on which the patient lies, normally there will be no 
alteration of the position of the back ; if, however, there is a limitation 
in the normal extension of the limb, the back will be arched up as the 
popliteal space is pressed down. This limitation of extension can also 
be determined by examining the patient lying upon the belly. If one 
hand be placed on the sacrum and the thighs be alternately raised from 
the surface on which the patient lies, a difference in the amount of 
motion at the hip without moving the sacrum can easily be determined. 
The limit to the amount of abduction or adduction is determined by 
placing one hand on the anterior superior spine of the ilium on the 
sound side, and with the other hand gently abducting or adducting the 
suspected limb ; when limitation is present the pelvis, of course, moves 
with the diseased limb. For detecting limitation of rotation the thigh 
should be flexed to a right angle and rotation tested in that position. 
The motions most often limited in early hip disease are abduction, hy- 
perextension, and rotation when the thigh is flexed to a right angle. 
The loss of motion in this group is always suggestive. 

Careful inspection in the early stages of hip disease during manipu- 
lation will sometimes show fibrillary contraction of the muscles of the 
thigh, especially the adductors, on sudden or unexpected movement of 
the limb. 

In the later stages of hip disease complete stiffness of the joint may 
be present. If this is due to muscular spasm it disappears, in a meas- 
ure at least, under complete anaesthesia. An ankylosis of the hip-joint 
is as stiff under full anaesthesia as without it. 

Any catch in the motion of the joint in any part of its arc is exceed- 
ingly suspicious, no matter how slight it may be. 

II. Lameness. — At the earliest stages the limping may be intermit- 
tent and not constant, and, again, it may be so slight that it is practi- 
cally imperceptible, so that its absence does not exclude hip disease. 
The diagnosis cannot be made alone from watching the child walk. 



TUBERCULOUS DISEASE OE THE HIP. 



103 



III. Attitudes. — Abnormal positions of the diseased limb at an early 
stage of the disease are caused by the action of the muscles holding the 
limb stiffly in a distorted position. Neither adduction nor abduction of 
the limb is usually recognized by the patient as such, but the complaint 
is made that the limb seems longer or shorter than the other. The 
pelvis is tilted, which gives a practical lengthening of the limb if ab- 
duction is present, and in the same way the limb appears shorter to the 
patient if adducted. The tilting of the pelvis can be recognized by 
drawing a line from the anterior superior spine of one side to that of 
the other. This should normally be at right 
angles with the long axis of the body. In this 
way have arisen the terms of apparent or prac- 
tical shortening and lengthening, which have 
given rise to some obscurity, being often con- 
fused with real or bony shortening. 

The accompanying diagrams will explain 
the matter. The normal position of the pelvis 
in relation to the limbs is shown in heavy lines 
in Fig. 1, where both 
legs are at right an- , 1 

gles to the pelvis, the 
normal position for 
standing and walking. 
If, however, the right 
leg is fixed by muscu- 
lar spasm in an ad- 
ducted position, A E, 
the relation is changed, 
and when the patient 
stands erect the legs 
must be made parallel 
to permit walking or 
standing on both feet, 
and this can be done 
only by tilting the 
pelvis to the position shown in Fig. 2, It will be seen by the tilt- 
ing that the leg A C is carried up with that side of the pelvis, and 
to all appearances the leg A C is shorter than the leg B D, when the 
patient stands or lies straight. Thus adduction results in apparent 
shortening of the adducted limb as compared with the other when the 




\ 



Tig 3. 



Fig. 106.— Diagram Showing- 
Practical Shortening from 
Adduction. 



FIG. 107.— Diagram Showing 
Apparent Shortening and 
Lengthening of Leg due to 
Tilting of the Pelvis. 



patient lies straight. 



In the same way in Fig. 3, if the leg A Cis ab- 



ducted to the position A F, the pelvis must be tilted in the opposite 
direction to make the legs parallel, because the angle FA B is a fixed 
quantity, and so the pelvis is tilted, and A £7 for practical purposes is 



104 ORTHOPEDIC SURGERY. 

longer than B D, and the amount of apparent lengthening depends upon 
the amount of abduction. 

A patient then with fixation of one leg in a position of adduction 
has a deformity which results in a lifting of that leg from the ground 
when he stands or walks, for the tilting of the pelvis has caused a prac- 
tical shortening of that leg. In the same way abduction causes the 
opposite tilting of the pelvis and a practical lengthening of the diseased 
leg. So that the term apparent or practical shortening can be applied 
to the inequality of the legs noticed in walking or standing, which 
results from the tilting of the pelvis. Practical shortening can be esti- 
mated by measuring from the umbilicus to each malleolus when the 
patient lies or stands straight. 

Real or bone shortening is different from apparent shortening. It 
results from the retarded growth or atrophy of the affected limb or 
from the destruction of bone in the hip-joint. Real shortening is meas- 
ured by a tape from the anterior superior spines of the ilium to the 
malleolus on each side. 

The amount of enlargement of the acetabulum and absorption of 
the head of the femur which has taken place may be estimated by de- 
termining the amount that the trochanter of the femur has risen above 
its normal position. If the patient lie upon the well side, and Nelaton's 
line (from the anterior superior spine to the most prominent part of the 
tuberosity of the ischium) be drawn over the affected hip, the thigh 
being somewhat flexed, it should pass just above the upper margin of 
the trochanter ; if the trochanter is above this line, it is an evidence of 
destruction of part of the head of the femur or enlargement upward of 
the acetabulum. 

Estimation of Adduction and Abduction. — The amount of de- 
formity due to adduction or abduction or flexion of the limb is an im- 
portant index of the progress or activity of the disease and should be 
carefully estimated. 

A simple method has been devised by which it is possible to esti- 
mate with the tape measure alone the angle of either abduction or ad- 
duction .present. 

In measuring patients it is found that real and practical shortening 
of a leg are often not the same in the same patient, and that the differ- 
ence between them varies in proportion to the amount of deformity 
present. This was taken as the basis for constructing the following 
working table. The mathematical process by which it was made is 
given in full in the original article. 1 To measure by this method, the 
patient is made to lie straight, with the legs parallel. Real shortening 
is measured with the ordinary tape measure, and apparent shortening is 
obtained in the same way. It may be repeated that real or bony short 
1 R. W. Lovett: Bost. Med. and Surg. Journal, March 8th, 1888. 



TUBERCULOUS DISEASE OF THE HIP. 



105 



ening is measured from the anterior superior iliac spines to each malle- 
olus, and that practical shortening is found by a measurement taken 
from the umbilicus to each malleolus. The difference in inches be- 
tween the two kinds of shortening is seen at a glance. The only addi- 
tional measurement necessary is the distance between the anterior 
superior spines, which is taken with the tape. Turning now to the 
table, if the line which represents the amount of difference in inches 
between the real and apparent shortening is followed until it intersects 
the line which represents the pelvic breadth, the angle of deformity will 
be found in degrees, where they meet. If the practical shortening is 
greater than the real shortening, the diseased leg is adducted ; if less 
than real shortening, it is abducted. Take an example: Length (from 
anterior superior spine) of right leg, 23; left leg, 22^ ; length (from 
umbilicus) of right leg, 25; left leg, 23; real shortening y? an inch, 
apparent shortening 2 inches; difference between real and practical 
shortening, iy 3 ' inches; pelvic measurement, 7 inches. If we follow 
the line for iy 2 inches until it intersects the line for pelvic breadth of 
7 inches, we find 12 to be the angular deformity; as the practical 
shortening is greater than the real, it is 12 of adduction of the left leg. 
If apparent lengthening is present its amount should be added to the 



amount of actual shortening. 



Table I. 









Distance 


between Anterior Superior Spines 


in 


nch 


es. 








bi) 


1L 

I 

2 

*% 
2% 

3 

3X 

3% 

3U 

4 


3 


3 l A 4 


A l A 


5 


S l A 6 


6/ 2 


7 


1% 


8 


8y 2 


9 


9. 


4 10 


1 1 


12 


13 


'5 


5~ 


4 D 


4" 


3 


3° 


2° 


2° 


2 


2° 


2" 


2^ 


2° 


2° 


i° 


i° 


i° 


i 3 


i° 


5- 




10 


8 


7 


6 


5 


5 


4 


4 


4 


4 


4 


4 


4 


3 


3 


3 


3 


2 




14 


12 


ii 


10 


8 


8 


7 


7 


6 


6 


5 


5 


5 


4 


4 


4 


3 


3 


<u 


19 


17 


14 


13 


11 


10 


9 


9 


8 


7 


7 


7 


6 


6 


6 


5 


5 


4 


< 


i 25 


21 


18 


16 


14 


l 3 


12 


11 


10 


9 


9 


8 


8 


7 


7 


7 


6 


6 


a 


1 
30 


25 


22 


19 


17 


15 


14 


r 3 


12 


12 


11 


10 


10 


9 


9 


8 


7 


7 


* 


36 


3° 


26 


23 


20 


18 


17 


15 


14 


13 


l 3 


12 


1 1 


10 


10 


9 


8 


8 


2h 

CD 

Si 


42 


35 


30 


26 


23 


21 


19 


18 


16 


15 


14 


14 


J 3 


12 


12 


10 


10 


9 




40 


34 


3° 


26 


24 


21 


20 


19 


17 


16 


15 


14 


14 


13 


12 


11 


10 






39 


34 


29 


27 


24 


22 


21 


19 


18 


17 


16 


15 


14 


13 


12 


1 1 










38 


32 


29 


27 


25 


23 


21 


20 


19 


18 


17 


16 


14 


13 


12 


u 

.5 








42 


35 


32 


29 


27 


25 


23 


22 


21 


19 


18 


18 


16 


14 


13 


.S 










39 


36 


32 


30 


27 


26 


25 


22 


21 


20 


19 


17 


15 


14 




a 
<d 












40 


35 


33 


30 


28 


26 


24 


23 


22 


21 


19 


17 


16 












•' • 




38 
42 


35 


32 


3° 


28 


26 


25 


23 


22 


20 


18 


17 


Q 


38 


35 


32 


30 


28 


26 


25 


23 


21 


19 


18 



io6 



ORTHOPEDIC SURGERY. 



Estimation of Flexion. — The flexion deformity of the thigh may 
be measured by a similar method. 1 The patient lies upon a table flat 
on his back and the surgeon flexes the diseased leg, raising it by the 
foot until the lumbar vertebrae touch the table, showing that the pelvis 
is in the correct position. The leg is then held for a minute at that 
angle, the knee being extended, while the surgeon measures off two 
feet on the outside of the leg with a tape measure, one end of which 




A^=— c 

FIG. 108.— Estimation of Flexion. 



is held on the table (so that the tape measure follows the line of the 
leg) (A B). From this point on the leg (B) where the measurement 
of two feet ends, one measures perpendicularly to the table (B, C), 
and the number of inches in the line B C can be read as degrees of flex- 
ion of the thigh, by consulting Table II. For instance, if the distance 
between the point on the leg and the table is 12^ inches, it represents 
31 ° of flexion deformity of the thigh. 

Table II. 



In. 


Deg. 


In. 


Deg. 


In. 


Deg. 


In. 


Deg. 


o-5 


1 


6-5 


16 


12.5 


31 


18.5 


5° 


1.0 


2 


7.0 


17 


13.0 


33 


19.O 


52 


1.5 


3 


7-5 


19 


^Z-S 


34 


i9-5 


54 


2.0 


4 


8.0 


20 


14.0 


36 


20.0 


56 


2-5 


6 


8.5 


21 


14-5 


37 


20.5 


58 


3-o 


7 


9.0 


22 


15.0 


39 


21.0 


60 


3-5 


9 


9-5 


24 


15-5 


40 


21.5 


63 


4.0 


10 


10. 


25 


16.0 


42 


22.0 


67 


4-5 


1 1 


10.5 


27 


16.5 


43 


22.5 


70 


5-o 


12 


11. 


28 


17.0 


45 


23.0 


75 


5-5 


14 


n-5 


29 


i7-5 


47 


2 3-5 


80 


6.0 


15 


12.0 


39 


18.0 


48 


24.0 


90 



If the leg is so short that it is impracticable to measure off twenty- 
four inches, one can measure twelve inches ; ascertain from here the 
1 G. L. Kingsley : Bost. Med. and Surg. Jour., July 5th, 1888. 



TUBERCULOUS DISEASE OF THE HIP. 



107 



distance to the surface on which the patient is lying in a perpendicular 
line in the same way, then doubling this distance and looking in the 
table as before, the amount of flexion is found. 

Thomas' test for flexion is one which is sometimes of use for a rough 
estimation of the amount of flexion deformity. The patient lies on the 
back and the well thigh is flexed on to the abdomen and held there. 
This places the pelvis in the correct position, with the lumbar spine in 
contact with the table, and the diseased thigh is by this naturally 




FlG. 109. — Thomas' Test for the Estimation of Flexion of the Diseased Leg in Hip Disease. 



thrown into a position of flexion if such deformity exists. It is not 
suitable for use in cases in which the hip is sensitive, nor, as a rule, in 
the case of adults. 

IV. Atrophy. — Atrophy is a symptom of great significance. Its 
absence in real hip disease is most unusual, its presence suggestive 
but not diagnostic, for it exists in acute joint inflammation of any 
type. 

The measurement for atrophy is made with a tape measure by tak- 
ing the circumference of both thighs and both calves at the same level 
on each side. The conventional places for such measurements are at 
the middle of the thigh and the middle of the calf. 

V. Swelling. — The existence of deep thickening over the front of 
the hip-joint or behind the trochanter is of great significance, and of 
the signs mentioned is the one least likely to be present in cases simu- 
lating tuberculous hip disease. It is not easily recognized. Thicken- 
ing of the trochanter major is a diagnostic sign of assistance. 

Pain. — The significance of pain has been mentioned. " Night 
cries " characteristic of hip disease have already been mentioned ; they 
are extremely significant in pointing to the probable existence of seri- 
ous joint disease, but they may exist in cases which do not prove to be 
real hip disease. It is no sign of the absence of hip disease when one 



108 



ORTHOPEDIC SURGERY. 



is able suddenly to jam the head of the femur into the acetabulum 
without causing pain— a diagnostic method sometimes relied on. Its 
violence makes it unjustifiable as well as untrustworthy. 

DIFFERENTIAL DIAGNOSIS. 

Some affections commonly mistaken for tuberculous hip disease in 
practice deserve notice. 

i. Synovitis of the hip, of traumatic, infectious, or rheumatic ori- 
gin, or from no assignable cause, may occur in children, but it presents 




FlG. no. — ^V-Ray. Femoral disease. Slight atrophy of femur and pubic bone. Erosion of 
head of femur. Thickening of neck of femur. 

the symptoms of beginning hip disease and a diagnosis is not practica- 
ble in the early stages; the fact that the symptoms occur after a fall 
must not be allowed too much weight as arguing in favor of synovitis. 

It is distinguishable from true hip disease only by its relatively 
briefer course. In synovitis the usual joint symptoms, such as atro- 
phy, muscular spasm, night cries, etc., may be present. 1 

Marked thickening about the joint is less noticeable in the early 
stages than in hip disease. 

1 Boston Med. and Surg-. Journal, cxxvii., 161. 



TUBERCULOUS DISEASE OF THE HIP. 1 09 

In adults, synovitis of the hip may come on clearly after a fall; 
there is no history of preceding disability, and muscular spasm and 
wasting are present. 

2. Lumbar Pott's disease may have for its first symptom a limp 
and a restriction of motion in one leg. This is due to the descent of 
pus in the psoas muscle or to an irritation and contraction of its fibres. 
As a rule, this limited motion is only in the direction of loss of hyper- 
extension, but it may take occasionally the form of a general restriction 
of motion and the joint may be sensitive to manipulation. The point 
to be determined is whether rigidity of the lumbar spine is present ; 
if so, Pott's disease is to be suspected. But sometimes in hip disease at 
a sensitive stage the tenderness of the joint is so great that on at- 
tempted flexion of the spine the erector spinae muscles are also spas- 
modically contracted and lead to the appearance of rigidity of the lum- 
bar spine. The diagnosis may sometimes be a very difficult one, and 
an opinion mast be withheld and the case kept under observation until 
characteristic symptoms of one affection or the other develop. Later 
in the history of lumbar Pott's disease a psoas abscess will often de- 
scend and may irritate the hip-joint on one or both sides; this may 
again so closely simulate hip disease that it is hard to tell whether the 
psoas muscle is causing all the trouble or whether the hip-joint is really 
involved. A test of the arc of abduction of the hip may be valuable 
in this connection, as this motion is impaired or lost at a comparatively 
early stage of hip disease. It is an excellent rule never to make a diag- 
nosis of hip disease without examining the spine to see if Pott's disease 
is present. 

3. Chronic arthritis deformans, morbus coxae senilis, which in many 
cases remains purely a synovitis without ostitis, begins sometimes idio- 
pathically without the history of even slight injury. A diagnostic 
point relates always to the age at which the patient is attacked, it being 
much less common in childhood, except in extensive cases in which 
other joints are affected. The presence of arthritis may, of course, be 
demonstrated in other joints. The x-ray is of value in showing bone 
proliferation. 

4. Acute Infectious Inflammation (Osteomyelitis) of the Hip Joint.— 
The symptoms are more acute than in hip disease, the swelling is 
greater, and the temperature higher as a rule. In young children 
the diagnosis is often obscure until operation is required by abscess. 
In Konig's collection of 758 cases of hip-joint inflammation there were 
568 tuberculous cases and no of acute infectious coxitis. 1 

5. Anterior Poliomyelitis. — At the stage of onset of infantile par- 
alysis there may be for a short time, in rare instances, marked pain and 
tenderness, with immobility of one limb ; ordinarily these symptoms 

1 Konig : "Die spec. Tub. d. Knochen und Gelenke." pt. ii., p. 123. 



HO ORTHOPEDIC SURGERY. 

are not accompanied by other symptoms of hip disease, but are ac- 
companied by loss of power of the rest of the limb as well as a loss of 
its normal warmth, rapidly followed by atrophy in the whole limb. In 
the late stages of infantile paralysis there is no stiffness at the hip- 
joint, but we note abnormal mobility in all directions and other evi- 
dences of infantile paralysis, such as distortion of the foot and knee, 
coldness, atrophy, and marked loss of power of certain muscular groups 
which make an error in diagnosis very unlikely. 

6. Congenital Dislocation. — Congenital dislocation of the hip-joint 
need not be mistaken for hip disease, as the clinical history of the 
former is of continued limp since the child commenced walking. The 
trochanter is above Nelaton's line. There are no symptoms of muscu- 
lar stiffness or limitation of motion of the hip in congenital dislocation ; 
in fact, no symptoms of hip disease except the limp in gait. Patients 
with congenital dislocation, however, at times have slight attacks of 
synovitis of the hip due to the imperfect mechanism of the joint, but 
these symptoms subside after a short rest. 

7. Hysterical joint affections, as they are to be diagnosticated 
from organic joint disease, will be considered more fully under the 
head of functional joint disease. It may be said here that the symp- 
toms of functional and organic hip disease may be much the same, the 
characteristic of the former being that they are variable in their inten- 
sity and not consistent with one another. 

8. Coxa vara, a distortion of the neck of the femur, gives rise 
to shortening and limping. The trochanter is higher than Nela- 
ton's line. There is either good motion at the hip-joint or the limita- 
tion is in the direction of abduction, while the flexion is free. The 
amount of limitation of motion is less than would be expected from the 
history of the case, which is of long duration. The diagnosis is aided 
by a skiagram. 

9. Knee-joint Disease. — Hip disease is often diagnosticated as 
"knee trouble," so that it seems worth while to call attention to the 
well-known fact that pain in hip disease is in most cases referred to the 
inner side of the knee. Examination will show which affection is 
present. 

10. Miscellaneous Conditions.— Perinephritis and appendicitis 
have been mistaken for hip disease. Such an error, however, must be 
rare. In the chronic forms of these affections there may be slight 
psoas contractions and the presence of iliac abscesses. In these affec- 
tions the limitation to motion of the thigh at the hip-joint is not general 
nor does it affect abduction, but it is most marked in the direction of 
limitation of extension. 

Periarticular disease, which has not yet attacked the joint or 
the epiphyses of the joint, is recognized with difficulty. Under the 



TUBERCULOUS DISEASE OF THE HIP. ill 

head of periarticular disease may be included inflammation of bursae 
and lymphatic glands, psoas abscess, or psoas muscular spasm from 
caries of the lumbar spine (psoitis). 

Sarcoma of the hip may be mistaken for hip disease or hip dis- 
ease for sarcoma. The x-ray may give assistance in the diagnosis and 
a piece of the growth should, of course, be removed for examination. 

Separation of the Epiphysis of the Femur. — Separation of 
the epiphysis or fracture of the neck of the femur, with the resulting 
distortion, which may be termed traumatic coxa vara, can be distin- 
guished from hip disease by the history aided by an jr-ray examination. 

PROGNOSIS. 

Under favorable surroundings the disease is one which tends to 
recovery in a majority of cases with more or less deformity. It is the 
duty of the surgeon to see that the chances of recovery are as favorable 
as possible, and when recovery occurs that it shall result with the least 
deformity and the most useful limb possible. 

Mortality. — The rate of the mortality due to the disease in hip dis- 
ease is greater among the poorly nurtured hospital cases than where 
after-treatment can be carefully looked after. 

Cazin ' reported, in 80 cases of suppurative hip disease treated at 
the hospital at Berck, in the course of five years, 55 per cent were 
cured; 12.5 per cent died; 25 per cent were not cured; 7.5 per cent 
were improved when removed. Of 288 cases collected by Gibney 
there was a mortality of 12.5 per cent from exhaustion, meningitis, and 
amyloid degeneration. In the Alexandra Hospital, London, there were 
100 deaths out of 384, a mortality of 26 per cent; of these, 260 were 
suppurating cases, and the death rate of these was 33.5 per cent. 
Forty-two per cent were reported cured. C. F. Taylor, of New York, 
has reported 94 cases in private practice, with only 3 deaths ; of these 
94, 24 were suppurating. Hueter reports the mortality of hospital 
cases at 27 per cent, and Billroth at 31 per cent. Jacobson reported a 
mortality rate of 73.2 per cent in 63 suppurating cases. The mortality 
rate from the disease alone has been generally considered to be about 30 
per cent. Shaffer and Lovett investigated 51 cases of cured hip disease 
which had been discharged from the New 7 York Orthopedic Dispensary 
at least four years previously, and found that 41 had remained cured. 
Of the remaining 10, 4 had died and 6 had relapsed, although 4 of the 
latter had been apparently cured a second time." 

Causes of Death. — Death may occur from (1) the generalization of 
tuberculosis in the form of phthisis, tuberculous meningitis, and gen- 

1 " Statistique des Coxalgies suppures," Bull, de la Soc. de Chirurgie, No. 5. 
1876.— Shaffer and Lovett: N. Y. Med. Journ., May 21st, 1887. 
2 N. Y. Medical Journal, May 21st, 1887. 



112 



ORTHOPEDIC SURGERY. 



eral tuberculosis ; (2) from amyloid degeneration of the viscera; (3) 
from exhaustion; (4) from intercurrent disease; (5) from septicaemia 
and exhaustion after suppuration. 

Functional Results. — Spontaneous cure may result in hip disease, 
but as a rule with little motion and with marked deformity. 1 

Recovery with complete motion after tuberculous hip disease is 
rare, but occurs even in hospital cases. From this condition to com- 
plete loss of motion the cases range according to the thoroughness of 
treatment, the severity of the disease in the individual case, and the 
resistance of the child. The earlier that treatment is begun the better 





Fig. hi. Fig. 112. 

FIGS, m and 112.— A Case of Hip Disease under Ambulatory Treatment. 
Motion to right angle. (Children's Hospital Report.) 



Result good. 



the outlook. A cure by ankylosis would be expected by the writers in 
perhaps a quarter or a third of hospital cases who followed out treat- 
ment properly. Some amount of motion would be expected in the 
majority of cases. The amount of joint motion is likely to diminish 
rather than increase in the years following treatment. 

The prognosis in hip disease in adults is less favorable than in chil- 
dren, as the process is generally of a severer type. 

1 New York Med. Rec, March 2d, 1878.— Trans. Am. Orth. Assn., vol. xi., p. 
256. 



TUBERCULOUS DISEASE OF THE HIP. 



"3 



If a cure with ankylosis takes place, an important practical point, 
as regards the use of the limb and locomotion, is the position in which 
ankylosis occurs.' 

Length of Time for Treatment. — It may be stated that at least from 






- . . ___, 



i 



two to three years will probably be 
needed in the treatment of a case 
of hip disease taken at an early stage, 
while protection to the joint will be ad- 
visable for two or three years more. 
The early discontinuance of treatment is a serious mistake, as re- 
J N. Y. Med. Record, March 2d, 1878.— British Med. Journ., August 3d, 1889. 



Fig. 113.— End Result in Patient with 
Hip Disease under Traction Treat- 
ment. Traction two and one-half 
years. Trochanter on Nelaton's 
iine (see Fig. 114). 



H4 



ORTHOPEDIC SURGERY. 



lapses are likely to occur when everything seems quiet. In the same 
way too early a discontinuance of the convalescent splint will often 
cause trouble. It is therefore much safer to err on the side of keeping 
on an apparatus unnecessarily long than to run what would seem to be 
a considerable risk of relapse. Even when a relapse does not occur, 

the too early discontinuance of 
treatment may lead to an in- 
crease in the flexion or adduction 
deformity. 

Distortion — The prognosis as 
to distortion, however, does not 
necessarily imply permanent dis- 
tortion ; for at the present time, 
after recovery from hip disease 
(the deformity still existing with 
severe flexion and adduction) 
these disfigurements can be en- 
tirely and permanently relieved 
by subtrochanteric osteotomy. 
It is, however, much more desir- 
able to correct malposition of the 
limb whenever it occurs than to 
allow it to become permanent, 
when its correction is a much 
more serious matter. The prog- 
nosis as to lameness will depend 
on the amount of malposition of 
the limb, the amount of motion 
present, and the degree of short- 
ening. 

Shortening. — Some shorten- 
ing will be present in a majority 
of cases if the disease continues 
for any time, but for practical use 
in locomotion the actual shortening is of much less moment than the 
position of the limb. At the close of the disease an average amount of 
shortening would be from half an inch to two inches, if one considered 
the severer cases. There may be no shortening, but if the head of the 
femur is dislocated it may be a shortening of from three to five inches. 
Actual shortening due to arrest of growth of the limb is beyond the 
control of the surgeon; but shortening from subluxation or dislocation 
of the head of the femur or enlargement of the acetabulum may be said 
to be due to a lack of thoroughness of treatment by traction. Perfect 
treatment may in some instances be impossible, from circumstances 




FlG. 115. — Cured Case with Marked Permanent 
Flexion, showing- Lumbar Lordosis. 



TUBERCULOUS DISEASE OF THE HIP. 115 

beyond the control of the surgeon ; but he should persistently bear in 
mind that subluxation and distortion from that source can be prevented 
by thorough treatment of the disease. 

Atrophy is never entirely cured in severe cases, but in the calf mus- 
cles it diminishes very much after the use of the leg is resumed. 

Abscess. — The significance of abscess is not very great ; it does not 
affect the ultimate amount of motion in the joint nor does it seriously 
increase the shortening. 1 

When abscesses occur in cases under careful mechanical treatment, 
the outlook is worse than in suppurative hip disease in general, because 
the careful treatment prevents the occurrence of abscess in all but the 
worst cases, so that in these the death rate is necessarily high. In a 
series of 63 cases of abscess from the Boston Children's Hospital, 2 the 
death rate was 40 per cent. Abscess occurred in 18.7 per cent of 574 
cases of hip disease under out-patient treatment which were analyzed. 3 

The amount of sensitiveness of the hip and pain in cases which are 
well treated should be slight, though nocturnal cries may persist for a 
while in the early stages. The reoccurrence of night cries late in the 
disease, or of acute sensitiveness of the joint, is most often a sign of 
inadequate treatment or of trouble coming in the joint ; most frequently 
it precedes the occurrence of abscess. 

Under conservative treatment carried out for a sufficient time one 
may expect a good functional result in the majority of cases. In few 
diseases is the benefit of thorough, skilled, and long-continued treat- 
ment more clear, and in few surgical affections can the surgeon attempt 
to check the progress of disease and influence recovery with greater 
probability of success than in hip disease ; but the surgical care and 
supervision should not be limited to the more acute stages of the affec- 
tion, but should be continued during the convalescent stage if the best 
results are desired. 1 

TREATMENT. 

General Considerations Influencing Treatment. 

It is to be remembered that the hip-joint differs from the other 
joints in that it is surrounded by strong muscles. These, in case of 
acute inflammation of the joint, develop a condition of exaggerated irri- 
tability analogous to the blepharospasm in ulceration of the cornea. 
This condition needs surgical consideration, as unless checked it will 

' Shaffer and Lovett : Loc. cit. 

-Boston Med. and Surg. Journ., November 21st, 1889. p. 503. 

3 Lovett : " Dis. of Hip," p. 117. 

4 The report of certain representative cases, with the results obtained in them. 
will be found in the second edition of this book. p. 241. They are omitted in the 
present edition as unnecessary. 



Ii6 ORTHOPEDIC SURGERY. 

develop deformity and destruction of the joint. The means at the sur- 
geon's disposal besides operative measures may be classed as means of 
fixing the joint, distracting the joint, and protecting it from injury, and 
involve a consideration of methods of (i) fixation, (2) traction, (3) pro- 
tection. 

The treatment of tuberculous ostitis of the hip-joint is based upon 
the same principles that are of importance in the treatment of tuber- 
culous ostitis of other joints, modified by the special anatomical condi- 
tions of the hip. 

The Principles of Treatment by Fixation and Traction. 

The object of fixing any joint affected with ostitis is to prevent an 
aggravation of the inflammation of the bone by the injury incident to 
motion. In an acutely inflamed condition the slightest motion involves 
joint injury and is to be avoided while the acute stage persists. In 
many joints it is necessary merely to secure firmly the bones forming 
the joint, and injury to the joint is prevented. In the hip-joint, how- 
ever, two factors militate against the efficiency of the ordinary methods 
of fixation : 

1. The difficulty met in securing the upper portion of the joint, viz., 
the pelvis, which, owing to the mobility of the lumbar vertebrae, is not 
secured by fixing the trunk. 

2. The muscular spasm of the strong muscles about the hip-joint. 
These muscles are in hip-joint inflammation in a state of reflex irrita- 
bility or of tonic spasm, and either crowd the head of the femur against 
the acetabulum by a continued muscular contraction or inflict upon 
the joint the injury of a sudden muscular contraction of all the 
muscles around the hip. The amount of this injury can be easily es- 
timated in even the weakest of children by an examination of a cross- 
section of the muscles. Adults who have experienced these attacks of 
muscular spasm liken the sensation to that of a blow of a sledge-ham- 
mer upon the hip. 

The importance in the treatment of hip disease of this increased ar- 
ticular pressure is shown by pathological evidence, which demonstrates 
the destruction of the bones forming the joint in the direction of such 
pressure and the absence or diminution of such destruction where this 
exaggerated pressure has been diminished. 

The effects of traction, when thoroughly carried out, can be seen in 
the specimens shown in the figures. 

A comparison of such specimens with those of severe hip disease in 
which traction was not used speaks most emphatically for the thorough 
use of the method. 

But although these facts have been recognized, there has been a 
lack of exact knowledge of the amount of force necessary to counteract. 



TUBERCULOUS DISEASE OF THE BIT. H7 

exaggerated intraarticular pressure and when to apply it. To deter- 
mine this, a series of investigations were made by the writers, 1 which 
demonstrated that in healthy joints an appreciable amount of distrac- 
tion was possible in children by a traction force of twenty pounds ; but 
in certain cases this distraction did not take place immediately on the 
application of the traction force, which served at first as a stimulant to 
the muscles. In children suffering from hip disease in the chronic sup- 
purative stage, with disorganization of the articular ligaments, a trac- 
tion force of ten pounds caused distraction. In the late stage of hip 
disease, when the cicatricial contraction of the capsule and tissues has 
taken place, distraction is not effected by a traction force. In suppu- 
rative cases of hip disease with extensive disorganization of the cotyloid 
ligament, a slight traction force of a few pounds causes distraction. 
This can be easily demonstrated when a joint disorganized by hip dis- 
ease is cut down upon and the finger inserted into the joint. Although 
under attempts at fixation of the hip-joint without traction the violence 
of the spasm of the muscles of the hip-joint diminishes, it is impossible 
to prevent entirely injurious muscular spasm without traction, and it 
will also be found that cases treated by so-called fixation alone will 
mean a greater danger of pressure destruction of the head of the femur 
and wandering of the acetabulum than when traction is efficiently ap- 
plied. 

It would appear that no thorough fixation of the inflamed hip-joint 
is possible without traction, and that when a patient is suffering from 
an acute condition of tuberculous ostitis to such an extent that all mo- 
tion is injurious, it is also necessary to provide for protection of the 
joint from injurious muscular spasm. 

The consideration of the treatment of hip disease for practical pur- 
poses may be divided into : A, The treatment of the acute stage ; B, the 
treatment of the subacute stage ; and C, the treatment of the conva- 
lescent stage. 

A. The Treatment of the Acute Stage. — Treatment at this stage 
demands arrangements which will prevent movement of the joints and 
pressure from muscular spasm. To prevent movement of the hip-joint, 
the ordinary gas-pipe bed-frame (Chapter XXL, 9) already described 
will be found of practical value. The child is placed upon the back 
upon this frame, and the shoulders, pelvis, and unaffected leg are se- 
cured by means of straps. Traction is then applied to the length of the 
leg by a pulley attached to the foot of the bed. This pulley is arranged 
in such a way that it pulls upon the diseased leg in the line in which it 
is held when the pelvis is placed square upon the frame. If flexion is 
present the pulley is elevated, and if adduction or abduction is present 
the leg is pulled in or out. If the leg is pulled in a position of flexion, 
1 Children's Hospital Report, 1898. 



u8 



ORTHOPEDIC SURGERY. 



it is held in position by an inclined plane or by folded sheets placed 
under it. The amount of traction force to be used is a question of 
judgment in each case, but as much weight should be applied as can be 
borne without discomfort by the patient. The foot of the bed should 
be raised to furnish counter-traction. If the patient is too sensitive to 
be placed upon the bed-pan without discomfort, a hole should be cut 




FlG. ho. — Method of Securing Child to Bed Frame for Recumbent Treatment of Hip Disease 

without Deformity. 

in the covering of the frame to allow the bed-pan to be placed under 
the frame without disturbing the patient. The patient should be 
turned once a day to have the back rubbed with alcohol, and this should 
be done with extreme care. Traction should be made upon the leg 





* 








• 4- 


[II 








Aii 


*r~ 


4 


' / S 


/ <^i 


^M^^i^dfll^H 


i 




p* 


" 


!__■■ ^ 




mtmm* .... „ y . 


'< i . 



Fig. 



Traction bv Inclined Plane. 



when the patient is turned and the hip-joint should not be moved dur- 
ing the process. In cases in which traction efficiently used does not 
afford relief, lateral traction may be added. This is furnished by 
means of a cloth band passing around the inner side of the upper part 
of the thigh which runs straight out, and is attached to a weight hang- 
ing over the edge of the bed. Resistance to this pull is furnished by 



TUBERCULOUS DISEASE OE THE HIP. 



19 



another cloth band running around the ilium on the diseased side, pass- 
ing around the patient, and over the other side of the bed to be attached 
to another weight. The amount of these weights is to be determined 
by the comfort of the patient. Traction during the acute stage may 
also be furnished during recumbency by the application of a long trac- 
tion splint, which is used in place of the weight and pulley traction. 
In this case the patient lies upon the bed-frame wearing the traction 
splint. The use of the weight and pulley during recumbency without 
the use of the bed-frame is ineffectual, as the patient lies upon a sag- 
ging mattress and fixation is not afforded to the diseased hip. 

B. The Treatment of the Subacute Stage.— During the subacute 
stage of the disease it is desirable that the patient should go about as 




Fig. 118.— Lateral Traction in Hip Disease. 

far as is compatible with the welfare of the diseased hip. The most 
efficient mode of treatment during this stage is to be found in the use 
of the traction splint, which furnishes not only traction, but also some 
restriction of motion. Unrestricted activity is not desirable at this 
stage. The patient's day should be a short one, broken by a period of 
recumbency. While wearing the splint the patient should sleep upon 
the bed-frame arranged in the manner described in speaking of the 
acute stage of the disease. 

Traction Splints. 

Traction splints exert their power upon the joint by virtue of pull- 
ing down the leg against a counter-point of pressure furnished by the 
perineum. A number of appliances have been devised for the purpose 
of traction, the principle of which is practically the same, viz., perineal 
resistance with a pulling force exerted on the limb. 



120 ORTHOPEDIC SURGERY. 

The traction splint (Chapter XXI., 10) in common use is developed 
from the traction splint originally devised by Dr. Henry G. Davis. 
The modifications by Dr. C. F. Taylor and Dr. L. A. Sayre were, how- 
ever, of great importance in establishing the usefulness of the appliance. 
A traction appliance consists of an outside steel upright reaching from 
the trochanter to below the foot ; at the upper end is a horizontal rigid 
pelvic girdle in which the patient is secured by one or two perineal 
straps ; to the bottom of the shaft is attached some appliance for exer- 
cising traction upon the limb, the latter being held to the bottom of the 
splint by means of webbing attached to adhesive plaster straps. 

The adjustment of traction is easily provided for in several ways. 
One is by means of a sliding rod moving within a tube, the extension 
of the splint being controlled by means of a key and ratchet, a catch 
securing the rod when in the proper position. 

The lower end is furnished with a broadened piece, bent so as to 
pass under the foot, and straps are attached to it which can be buckled 
into buckles secured to the adhesive plaster on the patient's leg. 

A cheaper arrangement for traction can be furnished by means of a 
small windlass on the footpiece of the splint, turned by a key with a 
ratchet. 

Perineal Bands. — These may be made of webbing covered with Can- 
ton flannel or chamois skin. Leather sewed smoothly around a leather 
strap is the cleanest perineal band of all ; but in the hands of careless 
persons it becomes hard with the constant wetting from urine, and is 
liable to chafe. 

Two perineal bands are better than one, as furnishing better coun- 
ter-resistance to traction and checks to adduction of the limb. 

The perineum should be kept powdered, and it should be bathed in 
alcohol daily. When an excoriation appears the perineal band should 
be covered with linen which is well spread with vaseline or zinc oint- 
ment and changed often. If the chafed spot becomes worse, the peri- 
neal band on that side should be removed and the other band entrusted 
with the whole weight ; or the child should be put to bed, the splint 
removed, traction by means of a weight and pulley in bed being used 
for a short time until the perineum is healed. Ordinarily, with proper 
care and cleanliness, the perineum is able to bear after a short time all 
the pressure needed. 

Traction Straps'. — The readiest way to obtain the hold upon the limb 
for an extending force is by means of adhesive plaster applied as indi- 
cated in the diagram. It should be applied firmly to the thigh above 
the knee. If applied to the leg alone, traction falls upon the knee and 
may cause relaxation of the ligaments of that joint. Efficient plaster 
should be used, of a kind that will adhere readily without being heated. 
A plaster prepared with a combination of oxide of zinc will be found 



TUBERCULOUS DISEASE OF THE HIP. 



121 



to irritate the skin less than the ordinary surgeon's adhesive plaster. 
The plasters should be changed every three or four weeks, or oftener 
if they cause irritation. They can readily be removed, if the skin and 
plasters be thoroughly moistened with benzin or ether. If any portion 
of the limb is chafed by the plaster, it may be protected by means of a 





Fig. 



-Traction Hip Splint Applied, 
Front View. 



FlG. 120.— Traction Hip Splint Applied, 
Back View. 



cloth covered with ointment placed over the part, and the plaster be 
applied over the cloth and the whole limb ; or if the charing is exten- 
sive, the whole limb can be covered with zinc ointment and protected 
by a smooth bandage, and the plaster put on over the bandaged limb. 
This will require frequent renewal, but will answer temporarilv. A 
bandage applied over the plaster impedes the circulation and increases 



122 



ORTHOPEDIC SURGERY. 



the danger of eczema or chafing. If a bandage is applied over the 
plaster and worn for a few hours after it is first put on, sufficient adhe- 
sion of the plaster will be secured if proper plaster is used. In certain 
oases an obstinate eczema is occasioned by the adhesive plaster, and it 




Fig. i2i.— Traction Hip Splint 
Applied, Side View. 



FlG. 122. — Traction Hip Splint, High Sole and Crutches 
Applied. 



is necessary to have recourse to some other means of extension. Sub- 
stitutes for plaster are to be found, gaiters applied to the ankle or 
straps above the knee. These, however, will slip if more than a slight 
traction force be applied, and are not as a rule satisfactory. Another 
form of traction strap can be made in the following way: Cloth is cut 



TUBERCULOUS DISEASE OF THE HIP. 



123 



to fit the thigh and leg accurately ; webbing straps and buckles or lac- 
ings are attached, which when tightened give a hold upon the thigh 
above the knee. If straps are sewed to this leather or cloth legging, 
they can be made to furnish fairly efficient traction ; but they are likely 
to slip, and are inferior to the simple ad- 
hesive plaster as a means of traction. 

Application and Use of the Traction 
Splint. — The traction splint is applied by 
having the child lie on the back while gentle 
traction is made on the leg by the hand to 
steady it. The pelvic band is passed around 
the child, buckled around the waist, and the 
perineal bands are fastened. The traction 
straps below the foot are then attached 










Fig. 



Fig. 123.— Double Upright Hip Splint Applied. (Dane.) 



-Leather Spica Trac- 
tion Splint. 



to the windlass or whatever extending apparatus is used, and as much 
traction applied as the child can comfortably stand. The straps around 
the leg are then fastened. When it is necessary to remove the splint 
or loosen the traction to care for the perineum, traction should be made 
upon the leg by the hand. 

Crutches. — With an efficient traction splint thoroughly applied, a 
sufficient amount of restraint of motion at the hip-joint can be furnished 



124 ORTHOPEDIC SURGERY. 

to enable a patient not in the acute stage of the disease to move about 
with the aid of crutches, the well limb being elevated by a raised shoe. 
In cases with any tendency to acuteness, however, thorough traction 
is essential, and walking on a traction splint without crutches is liable 
to cause perineal chafing and less efficient traction, as at each step on 
the splint the traction force is somewhat diminished, on account of the 
yielding of the perineal straps. In cases in which convalescence has 
been established, crutches may be dispensed with and less traction 
exerted. 

Modified Traction Splints. — Various modifications of the traction 
splint have been made, in the hope of securing greater fixation in con- 
nection with the traction and in this way to enable free locomotion 
without endangering the joint. The splint devised by Dane (Chapter 
XXI., 12) and the combination of the traction splint with a plaster or 
leather spica represent the most efficient forms of this apparatus. The 
objection to such appliances is that they neither fix the joint nor do 
they permit as efficient traction as that furnished by the traction splint 
without a modification. The arm extending up to grasp the pelvis or 
thorax acts as a lever which jars the hip as the trunk moves, and the 
greater the traction used the more injurious is the lever action. 

A plaster-of-Paris bandage over the trunk and affected limb (as far 
as the knee), over which a traction apparatus is applied, the traction 
straps being placed on the limb before the plaster bandage is put on, 
furnishes probably the most effective combination of traction and par- 
tial fixation. Less cumbersome than the plaster, but not as easily fur- 
nished, is a moulded leather spica splint made over a cast by a similar 
process of manufacture to that described in speaking of leather jackets 
(Chapter XXL, 3). Still another arrangement can be furnished if a 
cloth corset with lacing be made, enclosing the trunk and limb and 
attached to a Thomas hip splint (Chapter XXL, 13). If this is laced 
snugly to the patient the child can be lifted with but little jar to the 
hip, and a traction splint can be applied with but little additional diffi- 
culty. This combination is of service in exceptional cases in which the 
acute stage is longer than usual, but it is not necessary in ordinary 
cases in which a comparatively short thorough treatment by recumbency 
is followed by a subacute stage where the limitation to the hip motion 
is furnished by a well-applied traction splint. 

Fixation Splints. 

Ambulatory treatment by means of so-called fixation appliances 
without traction has been tried in many cases for many years at the 
Boston Children's Hospital. The results in comparison with those 
obtained where traction was efficiently and carefully applied to sim- 
ilar cases justify a strong statement as to the superiority of the em- 



TUBERCULOUS DISEASE OF THE HIP. 



125 



ployment of traction in the subacute stages of hip disease, not only 
on theoretical grounds, but because of the superiority of the results 
obtained as observed in a large number of cases carefully treated and 
carefully recorded. 

Ambulatory treatment by partial fixation without traction may be 
needed when but little nursing care can be furnished, and the surgeon 
should be familiar with the best methods of its employment. It is 
manifest that thorough hip fixation cannot be given if the patient is 
allowed to move about, as the pelvis cannot be thoroughly secured by 
any bandage or appliance. It is also true that the method, although 
imperfect, is better than no treatment. Through its use patients may 
be relieved of the acute symptoms. 

Plaster-of -Paris Splint. — The hip-joint may be fairly well immobil- 
ized by a plaster-of-Paris spica reaching from the axillae to the heel. 




Fig. 125.— Application of Plaster Spica Hip Bandage. 

It is made more efficient if the other limb is included by a double spica, 
which, however, prevents locomotion. With a bandage applied to one 
leg alone the patient can go about on crutches wearing a high shoe on 
the other foot. This forms the routine of treatment in many Euro- 
pean clinics, but the amount of effective fixation furnished is limited. 
The aim of this treatment is well expressed by a representative French 
-surgeon writing as follows : " It is ankylosis in good position that we 
pursue as the ideal of a cure in coxalgia.' 3 1 

What has been said of the plaster-of-Paris spica, even when so 
applied as to hold the thorax and the other leg, is true of metal and 
leather splints, which do not so completely hold the joint as that does. 
These lack fixative power by virtue of the little hold which they have 
upon the pelvis, and although in many cases of hip disease they serve a 

114 Late Excision of the Hip." Boston Med. and Surg. Journ.. July 1st, 1897. 



126 



ORTHOPEDIC SURGERY. 



therapeutic purpose in acting as an incomplete means of fixation, they 
cannot be advocated for general use. 

The Thomas Splint.— The Thomas hip splint (Chapter XXI., 13), 
invented by H. O. Thomas, of Liverpool, is an appliance much in use 
in England. It is a very simple apparatus, easily made, and having 
many points of usefulness. It consists of an iron bar extending down 
the back of the body and the diseased leg to a little above the ankle ; 
the upper end of this is attached to a chestpiece which is at right angles 

to the upright and en- 
circles the chest, fasten- 
ing in front. There are 
two circlets of iron 
which grasp the thigh 
and calf. The appli- 
ance is kept in place 




Fig. 126.— Plaster Spica Hip Bandage. 



FIG. 127. — Thomas' Splint 
Applied, Posterior View. 
(Ridlon.) 



by a wide chest band and a bandage around the limb, and can be 
bent to fit any degree of flexion existing in the diseased leg and 
applied to it in that position. The apparatus requires much skill in 
adjustment, as it is hard to fit and keep in place. There are two points 
in the use of the splint upon which Thomas laid much stress. The 
patient must not go about while muscular spasm and joint irritability 
are present, and the limb must not be disturbed even for purposes of 
examination unless absolutely necessary, and then only at intervals of 



TUBERCULOUS DISEASE OF THE HIP. 127 

months. The appliance prevents motion of any great amount, enables 
the patient to be lifted without jarring the hip, and prevents and cor- 
rects flexion of the thigh. In certain acute cases the pain may be in- 
creased by the Thomas splint, from the fact of the imperfect fixation 
furnished. For motion at the hip cannot be prevented as the leg and 
thigh are firmly held by the flat rod to which they are bandaged, and, 
as this rod extends up the trunk, to which it cannot be so firmly fixed 
as to prevent all motion when the patient turns in bed or moves. The 
upper end of the rod acts as the long arm of a lever, moving with 
every respiration if tightly applied, and on moving jarring the hip. 

A double Thomas splint is more efficient as a means of fixation, but 
it does not permit locomotion. In a single Thomas splint a raised pat- 
ten is put under the shoe of the well foot and crutches are used. 

Immobilization and Ankylosis.— Much has been written in reference 
to the danger of ankylosis incurred by the immobilization of diseased 
joints. 

That fixation of a healthy joint even for prolonged periods does not 
cause ankylosis has been demonstrated. 1 The most common cause of 
ankylosis in diseased joints is, of course, in the cicatrization of the 
inflamed tissues. Any measure which tends to limit inflammation 
tends materially to limit rather than increase the ultimate impairment 
of motion. 

Treatment of the Stage of Convalescence. — Protection of the joint 
from the whole or part of the jar in walking is useful in the convales- 
cent stage of hip disease. The need of this will be readily understood 
if it is remembered that in ordinary walking the whole weight of the 
body falls upon the hip when the limb is straightened and the heel 
strikes the ground. A tuberculous hip may be sufficiently cicatrized to 
resist slight injury, while the frequent impact of a weight of upward of 
forty pounds may in time produce a condition of congestion which will 
furnish a cause for lighting up a quiescent focus of tuberculosis. 

The simplest way to protect a joint is with the use of crutches, the 
sound limb being raised by means of a patten on the shoe of the sound 
limb, enabling the affected limb to swing free of the floor. 

Protection Splints. 

The ordinary " traction " splint, as described, can be used as a pro- 
tecting splint, as it is longer than the limb and passes under the foot, 
enabling the weight to be borne upon the splint instead of on the pa- 
tient's foot. Protection without traction (Chapter XXI., 11) can be 
furnished by omitting the sliding rod, and continuing the upright rod 
below the foot, and expanding it at the bottom into a crutch bottom to 
be shod with a rubber tip running down at the outside of the foot, or 
] N. Y. Med. Jour., May 17th, 1890. 



128 



ORTHOPEDIC SURGERY. 



by inserting it into a socket in the boot. The upright of the splint 
should be long enough that the patient's heel should not touch the 
sole of the boot, though the ball of the foot may do so. The greatest 
jar in locomotion comes as the heel strikes the ground at the com- 
mencement of the step. If this jar is broken by the splint, the remain- 
ing jar to the hip in the step will 
be diminished at the ankle and 
knee, and the hip sufficiently pro- 
tected, except during the acute 
stages of the disease. 





Fig. 12S 



-Crutch Tip Convalescent Hip 
Splint, Applied. 



Fig. 



Jointed Convalescent Hip 
Splint, Applied. 



The ordinary protection splint should be, like the long traction splint, 
an outside steel upright with a horizontal pelvic band at a level with 
the trochanter carrying perineal straps. It should be slotted below 
into a steel sole plate screwed to the bottom of the sole, and when the 
splint is in place and the perineal band buckled, the patient's heel 
should not touch the heel of the shoe, but hang an inch or less above 
it. A protection splint can be made hinged at the knee, and, if prop- 
erly adjusted, patients can walk about readily with but slight discom- 



TUBERCULOUS DISEASE OE THE HIP. 129 

fort. In this way reliable protection is secured during the long period 
of convalescence necessary for the thorough recovery of the affected 
epiphysis. 1 

If proper protection is neglected and not continued long enough, the 
jar of locomotion — the whole weight being thrown upon the epiphysis 
previously diseased — is sufficient to prolong the stage of irritability, to 
prevent complete cicatrization and ossification of the inflamed bone 
tissue, to promote contraction of the limb and distortion, and in many 
instances to give rise to relapses. 

It is not necessary in young children that the splint be jointed at the 
knee in a protection splint ; this is, however, of advantage in adults. 
As the patient's condition improves, the splint can be shortened and jar 
gradually be allowed to come upon the limb. Protection is needed for 
some years after the subsidence of active symptoms. The need for the 
reapplication of protection is indicated by a reappearance of stiffness or 
increased limping on removal of the splint. The older the patient and 
the more active the process the longer protection will be needed. 

Relapses. — Hip disease is not ended when the acute symptoms have 
subsided ; a process which requires so long a time for its development 
requires also much time for its disappearance. It is safer not to dis- 
continue traction and begin simply protective treatment as soon as the 
pain and acute symptoms are gone, and it is safer not to discontinue 
protective treatment until a long time has been given to the joint in 
which to recover itself. 

Termination of Treatment. — Patients apparently cured in childhood 
of hip disease, but with fixed or partially fixed joints, may suffer in later 
life from painful attacks from overstrain of the ligamentous attach- 
ments of the joints; this is especially true if any distortion remains un- 
corrected and the patient becomes heavy. This painful stage yields to 
the treatment by protection for a short time. If, however, much deform- 
ity persists, correction of the deformity is often necessary. Recur- 
rence of the tuberculous process in adult life in a hip which has been 
thoroughly cicatrized since childhood is rare. 

When ambulatory treatment is attempted it is desirable that every 
precaution against jar to the hip be taken. As it becomes clear that 
the danger of motion or jar at the hip has diminished, crutches can be 
laid aside for part of the time, with the continuance of traction as long- 
as there is a tendency to contraction of the limb or muscular spasm. 
Later traction may be discontinued, but protection still maintained. 

Traction should be given up only after the muscular irritability 
elicited by gentle manipulation has been absent for some weeks, until 
pain and night cries have been absent for months, and until there is 

1 " Mechanical Treatment of Hip-joint Disease." C. F. Taylor, New York ; and 
E. G. Brackett: Boston Medical and Surgical Journal. October 6th, 1887. 
9 



130 ORTHOPEDIC SURGERY. 

every reason to believe that the process is quiescent and only partial 
stiffness of the joint remains, due to inflammatory adhesions and not to 
muscular spasm, and that protective treatment should then be pursued 
for two or three years at least and discontinued gradually. 

Summary of Mechanical Treatment.— A systematic and graded 
treatment of hip disease is in this way provided, capable of meeting the 
successive indications in the usual course of a typical acute hip disease 
in its progress from an early destructive stage to recovery, first, by 
thorough fixation with protection of the joint from muscular spasm 
and traumatism ; second, by locomotion with a minimum of motion at 
the hip and protection of the joint from jar, with a check to exaggerated 
intraarticular pressure from muscular spasm ; and third, by freer motion 
at the hip, but with protection of the hip from the jar incidental to 
walking and a check to the development of deformity. 

As cases vary, the treatment will be changed to meet the variations 
according to the judgment of the surgeon. The period of fixative 
recumbency, which should be as short as possible, will in some cases be 
longer than others, owing to the activity of the inflammatory process. 
In some cases ambulatory treatment can be begun at once without the 
stage of thorough fixation with recumbency. This course of treatment 
is inadvisable while deformity or acute spasm is present, but may be 
demanded by the necessity of the case. In some instances an increased 
risk to the local lesion may be justified to improve through greater 
activity the general condition. 

The application of traction in hip disease to be of benefit needs to 
be carefully directed. As in aseptic surgery vigilance and efficiency on 
the part of attendants are necessary, while as in aseptic surgery a par- 
tial adoption of the method is better than its total rejection, yet the 
method is injurious if its imperfect use blinds the surgeon to the neglect 
of other essentials. A surgeon is not employing the aseptic method of 
treatment if he washes his hands in sterile solutions and poisons the 
wound with septic dressings. In a similar way the use of a traction 
splint in the case of a child with hip disease is not only not beneficial, 
but becomes injurious if it leads the surgeon to neglect the necessity of 
protecting an inflamed joint from undue motion. 

The care required in the application of traction splints and the un- 
satisfactory results following apparent treatment by traction splints in 
out-patient clinics have led many surgeons to abandon the use of the 
so-called traction splints, allowing the patient to walk about with 
crutches, with the thigh, leg, and trunk supported by fixation appliances. 

The Treatment of Complications. 

Abscess. — Abscesses due to hip disease may in the early stages be 
absorbed in some cases under prolonged treatment by recumbency. 



TUBERCULOUS DISEASE OF THE HIT. 131 

Abscesses may also be left to enlarge and break if for any reason 
this seems desirable in any individual case. If abscesses are well local- 
ized and increasing in size, and burst spontaneously, they often are thor- 
oughly evacuated, leaving a sinus which, after discharging for some 
time, finally heals. Often, however, the abscess is not completely 
evacuated. Some residue remains, and, gravitating along the lines of 
fasciae, it gives rise to the development of another abscess, until several 
collections of pus may be developed about the joint. 

The experience of the writers in treatment by aspiration and the 
injection of germicidal solutions has not been favorable for the same 
reasons as those mentioned in speaking of Pott's disease. 1 

Incision under strict antiseptic precautions is to be advised in all 
cases in which absorption seems unlikely; exploration of the joint cav- 
ity should be made if the abscess communicates freely with it, and pos- 
sibly softened bone may be scraped out. The abscess cavity should be 
examined for pockets, wiped out with dry gauze, and drained. Sinuses, 
as a rule, persist for months or years after operation." 

When efficient treatment is carried out, abscesses as a rule appear 
only in the severer cases, in which drainage is likely to be of benefit to 
the disease. The closure of abscess cavities by suture after the evacua- 
tion of their contents, while in rare instances it leads to permanent 
union by first intention, is not to be advised, as breaking down gen- 
erally occurs subsequently. It must be remembered that the tubercu- 
lous infection is not confined to the wall of the abscess, but extends 
into the surrounding tissues. 

Night Cries. — This troublesome complication usually disappears 
quickly after the establishment of thorough treatment by recumbency 
and strong efficient traction. It is indicative of an active condition of 
the process of epiphyseal ostitis. In some instances it persists for sev- 
eral weeks even under treatment. In such cases an abscess is usually 
developed. The employment of phenacetin and salicylate of soda :i has 
appeared to be of some efficiency in diminishing night cries. Although 
opiates, chloral, and bromide of potassium in large doses will often give 
relief, the use of them is to be avoided if possible. 

Deformity. — The deformities occurring are flexion, abduction, and 
adduction, or any combination of these. In the early stages of the dis- 
ease when malposition occurs it is best corrected by putting the patient 
to bed and making traction in the line of the deformity. 

Correction by the Traction Splint. — Slight cases of deformity 
can be corrected by the use of traction splints, which allow the patient 

1 N. Y. Med. Jour., March 2d, 1889. 

-Boston Med. and Surg. Jour., September 18th. 1890. — Orth. Trans., vol. ii., 
p. 87. 

: 'R. \V. Lovett: Boston Medical and Surgical Journal, April. 1889. 



H2 



ORTHOPEDIC SURGERY 



to go about with the aid of crutches. The traction splint naturally 
antagonizes adduction of the limb by virtue of its pulling the leg against 
a counter-point in the perineum which tends to abduct the leg to 
which the splint is applied. 

Correction by Recumbency. — In the severer cases rest in bed 
hastens correction. If the patient is allowed to roll about in bed, or 
sit up, or hold the limb flexed at the knee, it is manifest that no proper 
traction force is being used. 
It is obvious, therefore, 
that the patient should be 
fastened to a bed frame 
and traction made in the 
line of deformity. As the 




FIG. 130— Diagram to illus- 
trate the performance of 
■sub-trochanteric osteoto- 
my for the correction of 
ankylosis of the hip in a 
deformed position. The 
solid line indicates a linear 
■ osteotomy ; the dotted and 
solid lines together, a 
wedge-shaped osteotomy. 




Fig. 131.— Adduction Deformity Resulting from 
Hip Disease before Correction. (C F. Painter.) 



malposition of the leg diminishes under treatment, the line of the 
pull is made gradually more in the long axis of the body. The 
ill effect of a pulling force not in the line of the deformity in the 
acute stages of hip disease is evident. If an attempt is made to force 
the limb down in a case of flexion, and a pull be made in the line of the 
axis of the body, the head of the femur is crowded upward to the ante- 
rior edge of the acetabulum by the force applied at the end of the lever, 
viz., the femur, the contraction of the flexor muscles (holding the limb 
flexed) furnishing the fulcrum. In milder stages of the disease this is 
not so important as in the acuter stages, but it is a mechanical error in 



TUBERCULOUS DISEASE OF THE HIP. 



133 



any stage to attempt traction except in the line of the deformity. This 
error is often the occasion of increasing the pain and sensitiveness in 
cases of hip disease. 

Correction Under an Anaesthetic— In cases of resistant defor- 
mity treatment by traction is tedious and in the more obstinate cases in- 
effectual. In cases of this character the use of judicious force under an 
anaesthetic is advisable. Care must be exercised not to inflict a trauma 
upon tuberculous bone, but where 
resistance is firm, cicatrization of 
the diseased area can be supposed 
to have taken place, and often but 
little force is necessary to secure 
correction. Division of the con- 
tracted fascia lata and adductor 
muscles will be of assistance in 
some instances. After correction 
the limb should be fixed in a 
plaster-of -Paris spica bandage, a 
corrected position with slight ab- 
duction. When firm ankylosis is 
present manual correction will not 
be sufficient and recourse to oste- 
otomy will be needed. 

Correction by Osteotomy. — 
The operation in common use was 
devised by Gant ; ! in this the femur 
is divided below the trochanter 
minor. The anatomical reasons 
which he gave for this step were 
that the resistance of the psoas 
and iliacus muscles was set free 
and that a return of the flexion 
was not therefore to be expected, 
as when the bone was divided 
above the attachment of these muscles. He also called attention to 
the fact that in operating for ankylosis, after hip disease, it was 
desirable, if possible, to make the section through healthy bone and as 
far as possible from the original seat of the disease ; in this way dimin- 
ishing the liability of rekindling the old joint inflammation. 

Technique of Operation. — The osteotome is a chisel, which should 
possess a temper about halfway between that of a cold chisel and a car- 
penter's cutting tool, so that the edge of it will not be turned by the 
hardness of the bone. The cutting edge should be sharp and the width 
1 Lancet. December, 1872, p. S81. 




FlG. 132.— Adduction Deformity Resulting 
from Hip Disease after Correction. (C. F. 
Painter.) Same patient as Fig. 131. 



134 



ORTHOPEDIC SURGERY 



of the blade about half an inch. The blade should be marked with a 
line every half or quarter of an inch from the cutting edges, so that one 
can tell how deeply the osteotome has penetrated. A fair-sized wooden 
carpenter's mallet answers better than any of the lead or steel ones 
found in the instrument-shops. 

In the performance of the operation the patient lies on the side with 
a sand pillow between the legs, and the skin is sterilized carefully. The 
chisel may be driven in through the sound skin about an inch or an 

inch and a half below the great 
trochanter, according to whether 
one is operating upon an ado- 
lescent or an adult. The chisel 
should at first be held with the 
blade in the long axis of the 
limb and turned when it reaches 
the bone until its edge is at right 
angles to the axis of the limb. 
The osteotome should then be 
driven into the bone by sharp 
blows with the mallet, turning 
the cutting edge first forward 
and then backward, so as to cut 
obliquely through the whole 
shaft. If the osteotome be- 
comes wedged it should be 
loosened by lateral motions and 
a thinner one substituted if 
possible. Any attempt at pry- 
ing with the osteotome may re- 
sult in breaking the blade and 
should be avoided. When the 
spongy tissue has been traversed 
by the blade of the chisel, it will 
come in contact with the opposite 
wall of solid outside bone and 
will at once be felt to be driven with greater resistance. Then the osteo- 
tome acts as a probe as well as a cutting instrument. The bone should 
not be entirely divided, but when it seems evident that only a shell is 
left, attempt should be made to fracture the femur — very little force is 
needed, and if the bone does not yield easily the chisel should be again 
driven in still farther — always loosening it after each blow of the mallet 
and directing the blade in a new direction. 

After the bone is broken, in most cases the flexed leg can be ex- 
tended and the adducted one brought straight, and no unnecessary 




FlG. 133. — Ankylosis at a Right Angle following 
Hip Disease, before Gant's Osteotomy. (C F. 
Painter.) 



TUBERCULOUS DISEASE OF THE HIP. 



135 



manipulation of the bone should be made. If the osteotomy has been 
efficiently performed little force is needed to correct the deformity. 
There is little bleeding and a small skin wound, unless it is necessary, 
as sometimes happens, to make a cut in the anterior surface of the 
upper thigh, to divide bands of contracted fascia which prevent full 
extension of the thigh. The patient should then be fixed in a carefully 
applied plaster spica bandage, which should secure the hip firmly in the 
corrected position. The anterior spines, the patella, and the vertebral 




Fig. 134.— Same Patient as Shown in Fig-. 133, 
after Osteotomy. (C F. Painter.) 




Fig. 



135. — Double Thomas 
Splint Applied. 



Hip 



spines should be well protected by padding to prevent sloughs. When 
plaster-bandage fixation is undesirable, on account of the condition of 
the skin, the patient should be placed on a bed-frame and a traction 
weight applied, pulling in the desired direction. 

Confinement to bed should last between five and six weeks. If 
it is desired to compensate for bone shortening it can be done by put- 
ting up the shortened leg in an abducted position. The latter will be 
found of assistance where the shortening is great, as the resulting tilt- 

ensrth of the limb. The risks 



ing of the pelvis adds to the practical 



6 ORTHOPEDIC SURGERY. 



attending the operation are slight. Hemorrhage is very rare — although 
accidents have been reported from pressure on the femoral vessels by 
sharp edges of bone. 1 Marked improvement in the general condition 
of the patient often follows the operation. 2 

After-Treatment,— .After the cessation of bed-treatment, fixation in 
a plaster-of-Paris spica should be continued for at least six weeks more. 
If fixation in the improved position is abandoned too early the deformity 
may recur. Deformity occurring during the acute stage of the disease 
should be rectified as it occurs and prevented from recurring. 

The ultimate functional results following the operation are excellent. 
Although there may be no motion at the hip-joint, the lumbar vertebrae 
are usually more movable than normal. The operation is indicated in 
all cases of severe deformity in which the distortion interferes seriously 
with locomotion. 

Shortening of the Limb. — Shortening of the limb after hip-joint dis- 
ease and after excision occurs in a certain number of cases ; nothing 
can be done to prevent it when it is due to arrest of growth. Preven- 
tion of the development of the disease and such use of the limb as is 
compatible with the safety of the joint, inducing proper circulation in 
the limb, may be regarded as the only means at our command. The 
shortening due to subluxation is in a large measure prevented by efficient 
treatment. 

Patients with much shortening of the diseased leg vary a great deal 
in the relief afforded by a high shoe ; sometimes they find it of the 
greatest possible benefit, while at other times it is a constant annoy- 
ance. The shoe can be raised by a cork sole, or more cheaply by an 
iron or wooden patten, or by an arrangement in which the foot, like the 
stump of an amputated limb, fits into the socket of a specially con- 
structed elongated boot, which conceals the shortening. 

Double Hip Disease. — During the acute stage of the disease recum- 
bency on a bed-frame and efficient traction by weight and pulley or by 
two traction splints is the best treatment. After the stage of spasm 
has passed, the patient can be carried about in a double Thomas splint 
and when convalescence is established, locomotion with traction or pro- 
tection splints and crutches is possible. The chief difficulty in treating 
double hip disease is in the prevention of deformity, not so much dur- 
ing the active stage of the disease, but after convalescence has been 
established. 

Deformity will probably not occur if patients are kept recumbent 
for a sufficiently long time to establish a perfect cure. If, however, 
they are allowed to walk or move too soon, before the joints are thor- 

! Post: Ann. Anat. and Surg., January, 1883, and Rev. de Chir., December, 
1881. — C. T. Poore : "Osteotomy and Osteoclasis," New York, 1884. 
2 Goldthwait : Orth. Trans., vol. xi., p. 280. 



TUBERCULOUS DISEASE OF THE HIP. 137 

oughly strong, weight must necessarily fall upon the affected limbs in 
walking. If these are not sufficiently recovered to sustain the weight, 
deformity may ensue. Even with very little motion in either hip-joint 
locomotion is often possible, although the gait is necessarily restricted. 

OPERATIVE TREATMENT. 

Curetting and Drainage of Tuberculous Areas in Hip Disease.— In 

cases of tuberculous ostitis of the hip, when the process is limited to 
sharply defined foci surrounded by firm bone, the condition may be said 
to resemble that presented by an abscess, and drainage of such a focus 
is desirable when the part affected is easily accessible, as in the knee or 
os calcis. But when the acetabulum or the epiphysis of the femoral 
head are attacked, it is difficult to secure satisfactory drainage and the 
removal of all diseased tissue ; nor is it, as a rule, easy in this region to 
determine, by means of a skiagram, the existence of a sharply defined 
focus. It has been shown ' that tuberculous changes may exist in bone 
in an early stage of development and on the borders of apparent tuber- 
culous cavities, and yet not be demonstrable in ;r-ray pictures taken of 
living subjects, especially when taken in the deeper structures. This 
procedure is most satisfactory when the process is situated near the 
trochanter, which may be trephined or tunnelled for the removal of de- 
tritus or sequestra. 2 When this is attempted for foci in close proximity 
to the hip-joint, it excites increased reflex irritability and exaggerated 
muscular spasm, and should in treatment be followed by thorough trac- 
tion to overcome the injury following increased intra-articular pressure. 
When this cannot be provided, or when the localization of the disease 
is not sharply marked, the method is of doubtful value in affections of 
the hip-joint proper. 

The operation is performed by exposing the part of the bone in 
which the focus has been located and removing it by thorough curet- 
ting. The cavity is then carefully dried and wiped out with strong car- 
bolic acid and alcohol or a 2.5-per-cent solution of formalin, and the 
wound closed, with the exception of a temporary gauze wick. The 
operation should be performed with as little unnecessary traumatism to 
the joint as possible. The operation is followed by traction in the re- 
cumbent position. 

Excision of the Hip- Joint.— This method of treatment is based upon 
the opinion that, when a tuberculous affection exists, repair is hastened 
by the eradication of the diseased portion. Excision is less to be advo- 
cated at the hip than at the knee or ankle, for the reason that it leaves 

1 Feiss : Journal of Med. Research, 1904 

-R. T. Taylor: Am. Joum. Orth. Surgery, vol. i., p. 232.— A. M.Phelps: 
N. Y. Med. Journ , September 5th. 1900. 



138 



ORTHOPEDIC SURGERY. 



a poor joint for weight-bearing purposes and because it is difficult and 
dangerous to remove the acetabulum, frequently primarily diseased in 
hip disease. Bardenheuer x has excised the acetabulum in twenty-six 
cases, eighteen of which were suffering from tuberculous ostitis and 
nine from osteomyelitis. He concludes as follows: that the complete 
resection of the hip-joint, including the acetabulum, is a severe but not 
fatal operation, though skill is required. It is indicated in all cases 
with septic involvement of the acetabulum and all cases of acetabular 

caries where conservative treatment has 
failed. The operation is performed by 
means of an incision made along the crest 
of the ilium, extending from the sacro-iliac 
synchondrosis to the anterior superior spine. 
The bone is to be cleared of muscular at- 
tachments down to the acetabulum. By 
means of a Gigli saw, the acetabulum is 
separated from the ramus of the pubis, the 
connection of' the ilium, and the descending 
ramus to the tuberosity of the ischium. It 
is easier to remove the acetabulum without 
opening the joint, which can be opened 
later and the head of the femur saved. If 
the head of the femur is involved it is re- 
moved, being sawn off at the neck. The 
and traction applied to the limb, placed in a 




FIG. 136.— Straight External In 
cision for Excision of th 
Joint. 



wound should be closed 
slightly abducted position. 

Excision in the early cases is not justified when conservative treat- 
ment can be carried out for a sufficient time and with thoroughness. 
The removal of the head and neck, moreover, removes from the socket 
one of the supports on which the trunk rests, and the hip is more 
mutilated than after the cure by the natural process of gradual absorp- 
tion, repair, and cicatrization, which leaves a firm though possibly anky- 
losed hip. After excision the hip is necessarily mutilated. The oper- 
ation is therefore reserved for the severer cases. 

Method of Operation. — Of the incisions in ordinary use the straight 
external incision is the one most commonly used and the most service- 
able. 

The incision should begin at a point midway between the anterior 
superior iliac spine and the great trochanter, the knife being pushed 
directly to the bone. The cut should curve to the top of the trochan- 
ter and then downward and forward, the length of the incision being 
from four to eight inches. 2 

'Bardenheuer: Festschrift d. Akad. f. prakt. Med. in Coin. 
2 Brit. Med. Jour . July 20th. 1889. p. 119. 



1904. 



TUBERCULOUS DISEASE OF THE HIP. 139 

The tissues should be incised down to the bone, the soft parts 
should be divided, and the capsule opened. It is best to incise the peri- 
osteum of the trochanter, and if possible with a periosteum elevator 
to free it with its muscular attachments from the bone. Sometimes 
the whole trochanter can be uncovered in this way. 

After having made the cut down to the trochanter and separated 
the periosteum on the outer side so far as practicable, the next step is 
to separate the soft tissues from the bone on the inner side, stripping 
back the periosteum as far as it exists as such. In advanced cases of 
hip disease, however, it will be found that all that it is practicable to do 
is to clear the periosteum from the outer aspect of the trochanter and 
then to separate the muscular attachments from the neck of the bone, 
keeping the knife as close to the bone as possible. Then passing the 
finger around the femur and adducting the leg slightly will raise the 
head of the femur out of the acetabulum, and the capsule can then be 
divided and the head of the femur thrown out into sight and sawed off, 
or the section can be made by a small saw or osteotome before dislocat- 
ing the bone if the finger is kept inside of the neck of the femur as a 
guard. If the head of the bone is dislocated, it is more easy to see the 
limit of diseased bone and to make the section well in the healthy tis- 
sue. The objection to dislocating the head of the bone before section 
is that fracture of the diseased and atrophied shaft of the femur may 
occur if it is done roughly, and also that periosteum may be stripped up 
from the inner aspect of the shaft and cause necrosis. When the head 
is adherent, it should be curetted or chiselled from its place. 

The acetabulum should be examined and any sequestra removed and 
any carious surface should be scraped with a Volkmann's spoon. If 
the acetabulum is perforated, the edges should be chipped off until the 
point is reached where the periosteum lining the pelvis is attached to 
the bone. 

After the operation a tube or a strip of gauze should be left in the 
most dependent angle of the wound and the rest may be sewed up if 
the tissues are not too much infiltrated with the products of inflamma- 
tion. A heavy antiseptic dressing should then be applied and the hip 
should be fixed either upon a frame with light traction or in a plaster- 
of- Paris spica with the limb in an abducted position. As soon as it is 
practicable the child should be allowed to move about with crutches, 
wearing, as an appliance to prevent subsequent deformity, a traction 
splint. 

It is impossible to remove all of the tuberculous material in excision 
of the hip; and this must necessarily lead to relapses and imperfect 
results in many cases. The mere removal of the head of the bone is a 
very incomplete measure for the eradication of the disease in those 
cases in which the tuberculous material has infiltrated all the tissues in 



140 ORTHOPEDIC SURGERY. 

the neighborhood of the joint. In many cases of extensive disease it 
is not easy to do a subperiosteal operation. In the severer cases the 
capsule is lax and partially destroyed, so that the finger when first 
introduced in the wound finds the head of the bone only loosely in con- 
tact with the acetabulum and dislocation is easily accomplished. 

The ultimate results in cases in which excision Was performed only 
after mechanical treatment had failed are as follows : 

Per cent 
Cases. of Deaths. 

Children's Hospital, Boston, 1 . . . .50 44.0 
Hospital for Ruptured and Crippled, New York 

(Townsend '), .99 51.5 

The causes of death after excision of the hip are, aside from the 
small per cent caused by the shock of the operation, due to the same 
causes as in hip disease not treated by excision, and it is certainly not 




Fig. 137. — Late Excision. Poor result. No motion. Hip painful. Walks with splint. 
Three years since operation. (Children's Hospital Report.) 

true, as has been claimed, that excision of the hip is a preventive of sys- 
temic infection. That general tuberculosis and tuberculous meningitis 
supervene in a certain proportion of cases of hip disease is a fact well 
known. Mr. Barker, an advocate of excision, in a lecture at the Royal 
College of Surgeons in 1888 on the treatment of tuberculous joint dis- 
ease, said that in no less than ten per cent of all deaths following excis- 
ion " rapid miliary tuberculosis supervened in such a way as to suggest 
strongly, if not to prove, that the surgical interference was the cause 
of the generalization of the disease." 

The statistics of Wartmann, based upon 837 resections, show that 
at least 10 per cent of all the deaths are caused by rapid general miliary 
tuberculosis, coming on in such a way that it is strongly suggested that 
the surgical interference stood in a causative relation. This point has 
been of late often alluded to, and the lesson to be drawn is that in 
excisions the work should be done cleanly, with as little tearing of tis- 
sue and opening of lymphatics as may be, with the most careful and 
constant irrigation. 

'Orth. Trans., vol. x. 



TUBERCULOUS DISEASE OF THE HIP. 



141 



Mortality. — It may be stated then, in brief, that resection of the hip- 
joint as an operation is attended by an immediate fatality of about 7 
per cent. The mortality of the disease after the operation cannot be 
estimated as less than 20 to 30 per cent, and when cases are followed 
up for several years it is higher still. 

Functional Results.— After excision of the hip-joint the mechanical 
conditions are not favorable to the formation of a firm joint. After 
operation the head of the femur 
is gone and part or all of the 
neck. The capsular ligament is 
destroyed, and the upper end of 
the femur lies loosely against the 
ilium — perhaps at the acetabu- 
lum, perhaps somewhere else, 
and out of this very uncertain 
contact a new joint must be 
formed if there is to be one, or 
else a union without motion. A 
new joint is established in suc- 
cessful cases. 

In these cases a synovial sac 
may develop, and the head of the 
bone is bound firmly to the ilium 
so that a comparatively useful 
hip-joint remains. But the use- 
fulness of the limb after success- 
ful excision is less than after 
recovery under non-operative 
treatment. In some instances 
a limb which was in excellent 
condition immediately after the 
operation becomes ultimately en- 
tirely useless. An illustration of 
this was reported by one of the 
writers ' in a patient seen five 
years after excision. In Cul- 
bertson's tables 2 the case is reported as follows: "(No. 464.)— Re- 
covered in six and two-thirds months; one-half inch shortening, 
almost perfect motion. Last heard from six and two-thirds months." 
Though the limb at the time of the patient's reported condition 
of cure was in a favorable condition, five years later the boy could 
only touch the floor with the toes of his affected limb, and was unable 

1 N. Y. Med. Jour., April, 1879. 

2 Transactions Am. Med. Assn.. 1876, p. 142. 




Fig. 138.— Result of Suppurative Hip Disease 
Treated by Traction after Three Years' 
Treatment, Showing Extreme of Possible 
Motion. 



142 



ORTHOPEDIC SURGERY. 



CI 



: 



to walk without crutch or cane and could bear little or no weight on the 

affected limb. 

It is difficult to determine definitely how large a proportion of useful 

limbs ultimately result in cases in which recovery has taken place after 

excision of the hip. 1 

In a series of 50 cases of excision of the hip done at the Children's 

Hospital from 1877 to 1895 it was possible a to report on the condition 

of 10, four years or more after oper- 
~ r $ ation. The interval ranged from 
four to fourteen years. One had 
his hip amputated later, a second 
was in poor general condition, but 
with the exception of the ampu- 
tated case no one of the patients 
used a cane or crutch ; one had 6 
inches of shortening, one 5, one 
4, one had 2 inches, and three had 
only 1 inch. The amount of mo- 
tion in flexion in those of the 10 
cases in which it was recorded 
was as follows: None, 25 , 40 , 
45 , 6o°, 65 , 8o°. 

Indications for Excision. — The 
indications for excision can be 
stated as follows : 

1. When conservatism is im- 
possible owing to lack of facil- 
ities for thorough treatment and 
the affection is rapidly progress- 
ive. 

2. When a progressive destruc- 
tive process has continued in the 
hip-joint unarrested by the most 
favorable conditions. 

3. When the process is so 
acute that it threatens not only the destruction of the joints but en- 
dangers life. 

4. When an extensive sequestrum is present. 

It must be borne in mind that results as to mortality after early 
excisions (before extensive destruction in the bone has taken place) are 




Fig. 139. — Late Excision of Hip. Motion pra 
tically perfect. (Same case as Fig. 140.) 



1 Cent. f. Chir. , 1879, No. 2. — Med. Times and Gaz., November 3d, 1877.— Orth. 
Trans., vol. vi., p. 124. 

2 Lovett: Orth. Trans., vol. x. 



TUBERCULOUS DISEASE OF THE HIP. 



143 



much more favorable than after late excision.' The results of careful 
conservative treatment, if carried out for a long time, are superior to 
those after excision in a majority of cases, and when conservative treat- 
ment is practicable it should be preferred. In large hospitals or among 
a poor and unintelligent class, conservative treatment is sometimes 
impracticable, and in such cases excision is resorted to earlier than 
would otherwise be justifiable, and the results gained are more satisfac- 
tory than when the operation is deferred. It must be evident, in com- 
paring the mortality and the results of excision of the hip with the 




Fig. 140.— Late Excision of Hip. Motion practically perfect. 

mortality and the results of conservative treatment, that excision has 
no place in the routine treatment of the disease, because its mortality 
is higher and its functional results are inferior. The operation has, 
however, a decided usefulness in late cases of hip disease, when it 
becomes distinctly a life-saving procedure, and in severe cases at an 
early stage when no home treatment or adequate hospital treatment for 
a long time is practicable. 

] Cent. f. Chir., 1894-96.— Congres de Chir., Proc. verbale, 481.— " Coxalgie 
Tuberculeuse." Paris. — Journ. de Med. et de Chir., Annales, iv., 3, 261. — Congres 
Fr. de Chir., 1895. ix.. 153. — Jalaguier: These d'Ag., Paris. 1886.— Archiv f. klin. 
Chir., xxiv.. 4. 719 



144 ORTHOPEDIC SURGERY. 

Although the writers have been able to gain thoroughly satisfactory 
results after excision of the hip, and in a few instances have had reason 
to regret not having resorted earlier to excision in cases in which con- 
servative treatment proved unsatisfactory, yet after years of careful 
experience in the treatment of hip disease by both conservative and 
operative methods they would unhesitatingly record their opinion that 
the conservative method of treatment is preferable to the operative and 
that resection is needed only in exceptional cases. 1 

Amputation. — The question of amputation of the diseased limb 
alone remains for consideration. The mutilation which results is the 
chief objection to the operation, and is but partially met by an artificial 
limb. An undoubted reformation of bone has taken place in the case 
operated upon by one of the writers. 2 

Absolute economy of blood — of the utmost importance in all hip 
amputations — is vital in cases reduced to the physical extremity seen in 
cases of hip disease undergoing this operation. 

The limb should be elevated and stripped of blood, and an elastic 
bandage is doubled and passed between the thighs, its centre lying 
between the tuber ischii of the side to be operated upon and the anus. 
A pad in the shape of a roller bandage is tied over the external iliac 
artery ; the ends of the rubber are drawn tightly upward and outward 
(one in front and one behind) to a point above the centre of the iliac 
crest of the same side. The front part of the band passes across the 
compress ; the back part runs across the great sciatic notch and pre- 
vents bleeding from the branches of the internal iliac. The ends of the 
bandage are tightened, and should be held by the hand of an assistant 
placed just above the centre of the iliac crest. 

The danger of hemorrhage may be still further diminished by trans- 
fixing the thigh from side to side above the line of incision and securing 
pressure with a steel skewer passing under the vessels. If rubber tub- 
ing be passed tightly around the ends of the skewer over the anterior 
surface of the thigh, the front vessels can be compressed and the same 
method can be applied to the posterior vessels (Wyeth's method). 
The operation in this way can be performed without the loss of any 
appreciable amount of blood, and there is time for due deliberation, as 
there is no danger of a death upon the table by a sudden gush of hem- 
orrhage. 

The operation of amputation at the hip-joint has been performed 
three times at the Boston Children's Hospital in extensive disease of 

1 E. H. Bradford : " Operative Dislocation and Drainage of the Acetabulum in 
Articular Disease." Boston Med. and Surg. Journ., 1901, cxlv., 240. 

2 Wyeth : Ann. of Surgery, xxv., 1897, 127. — Levison : Jour. Am. Med. Assn., 
June 24th, 1899, p. 1428.— Erdman: Ann. of Surgery, September, 1895. — Lancet, 
May 26th, 1883. 



TUBERCULOUS DISEASE OF THE HIP. 145 

the hip and pelvis, with operative success in all, but with ultimate death 
from amyloid disease in two cases. Ultimate recovery took place in 
one who grew to manhood and at twenty wore an artificial limb fitted 
to a stump in which reformation of the bone took place from the peri- 
osteum. 

The following conclusions would appear to be justified : amputation 
at the hip-joint, in hip disease, should be regarded as the very last 
resort, contraindicated by extensive amyloid degeneration of the viscera 
or a moribund condition of the patient. The chances of mortality are 
not greater than those in amputation of the thigh in general, and the 
chances of a permanent cure (barring the mutilation) would appear to 
be greater than after excision at the hip-joint. The amputation should 
be done subperiosteally whenever it is possible. 

Summary of Treatment of Hip Disease. 

It is difficult to summarize the treatment of hip disease, for the 
reason that cases differ greatly in severity ; some needing recumbency 
for a very long period, owing to a severe degree of sensitiveness or to 
the activity of the ostitis, while in other cases ambulatory treatment 
with proper appliances is sufficient without recumbency. 

The proper treatment of hip disease is, therefore, not the exclusive 
use of any splint, but the use of such means as may meet the indica- 
tions as they are present. During the acute stages, the hip-joint should 
be fixed efficiently in bed. This implies the use of thorough traction. 
Continued confinement to bed is not beneficial to the general condition 
of tuberculous patients, except temporarily during the acute stage ; and 
as soon as the acute symptoms have subsided the patient should be 
allowed to go about with the hip thoroughly protected against jar and 
spasm. This can be done by means of a traction splint, if efficiently 
applied, with at first the additional protection from crutches. 

If the acute symptoms return under this method, thorough rest in 
bed is again indicated in addition to efficient traction and fixation. If 
the acute symptoms diminish and there is less muscular rigidity at the 
hip-joint, greater freedom can again be allowed, and eventually traction 
discontinued, and the joint merely protected from jar. This should be 
continued so long as there is any danger of recurrence of active symp- 
toms or tendency to contraction. 

In brief, the hip should be fixed as long as it is sensitive, should be 
protected and distracted as long as there is muscular spasm, and pro- 
tected as long as it is weak. The best results are attained only by 
thorough treatment for a year at least, and careful supervision and 
protection for two or three subsequent years. Distortions of the limb 
should always be corrected as they occur. In many cases some motion 
can be saved at the hip-joint if treatment is not discontinued too soon. 



146 ORTHOPEDIC SURGERY. 

Abscesses can be treated on general surgical principles. Radical 
operative measures are needed only in exceptional cases if thorough 
conservative treatment can be secured. Out-of-door air, the best ob- 
tainable surroundings, with as much activity as the local conditions of 
the joint justify, stimulating the circulation by exercise, and improving 
the appetite and the metabolism, are the antidotes, at present available 
to the tuberculous condition. These, if combined with such surgical 
treatment as will protect the affected bone from frequent traumatism, 
may be relied upon to effect a cure in the greater number of cases of 
hip disease. 



CHAPTER IV. 
TUBERCULOUS DISEASE OF THE KNEE. 

Definition.— Pathology. —Clinical history.— Diagnosis. — Differential diagnosis. — 
Prognosis. — Treatment, (a) conservative. (&) operative I excision.— arthrectomy. 
— amputation). 

DEFINITION. 

The other names by which this affection is known are tumor albus, 
white swelling, scrofulous disease of the knee, chronic purulent or fun- 
gous synovitis of the knee, etc. 

The knee-joint differs in anatomical structure from the hip, in that 
the joint surfaces forming the knee are nearly flat and the facets in the 
tibia shallow. Owing to this fact, the tibia is easily drawn backward 
and flexed by the hamstring muscles, the flexors of the leg being 
much stronger than the extensors; at the same time it is rotated out- 
ward, the combination constituting the common and troublesome de- 
formity which is the characteristic one after severe tumor albus. 

The course of the disease in the knee does not differ in general from 
that in the hip, but the measures necessary for preventing deformity in 
the two joints are somewhat different. 

PATHOLOGY. 

Tumor albus, as it is seen in children, begins oftenest, if not always, 
as an epiphyseal ostitis of the tuberculous type. Like other forms of 
tuberculous disease, it is oftenest limited to certain portions of the 
epiphysis, and either the femoral or tibial epiphysis may be attacked 
primarily. Cases are occasionally seen, however, in which the primary 
focus is in the patella or in the head of the fibula. In children it is not 
uncommon to see an acute, apparently traumatic effusion gradually 
absorbed, leaving an infiltrated and thickened synovial sac. In the 
greater number of cases, however, the bone symptoms clearly precede 
the effusion. 

The pathological appearances of tuberculous joints have been so 
fully described in speaking of the pathology (Chapter I.) that it is not 
worth while to enter upon them here to any extent. 

In the severer cases a destructive, fungous, or purulent synovitis 

147 



148 ORTHOPEDIC SURGERY. 

generally develops, which becomes the characteristic feature of the 
process. This may end in a complete destruction of the joint or in 
arrest and recovery by absorption and cicatrization. 

CLINICAL HISTORY. 



The affection begins, as a rule, insidiously, with stiffness and limp 
in gait. The disease may be limited for a long time, and be manifested 

by an enlargement of the con- 
dyles or head of the tibia, or 
it may extend and involve the 
whole joint ; occasioning severe 
pain, swelling of the periarticu- 
lar tissues, effusion into the 
joint, periarticular abscess, and 
distortion of the limb (i.e., flex- 
ion and subluxation), and end- 
ing in a natural cure with fibrous 
or bony ankylosis and a distorted 
limb, which may be more or less 
serviceable, according to the 
distortion; or the affection may 
result in such extensive sup- 
puration as to endanger life 
from septic or amyloid changes. 
Sometimes in cases of moderate 
severity an attack of severe 
pain supervenes, and an acute 
stage is reached, when the limb 
is flexed at the knee, hot and 
tender to the touch, and sen- 
sitive to any jar. Under proper 
treatment this stage gradually 
subsides, and there may be left 
impairment of motion. En- 
largement of the bone, if it 
persists for any length of time, 
is characteristic of chronic epiphysitis of the knee. 

In the milder cases, arrest of the disease may occur at any time with 
more or less complete restoration of the joint. In the severer cases 
suppuration may follow, with the establishment of sinuses. The de- 
structive process may become so extensive that excision or amputation 
is required. In general, the affection is favorably affected by proper 
treatment. 




Fig. 141.— Tumor Albus. Joint shows general 
tuberculous process, without visible connec- 
tion with the primary focus ; a cavity in head 
of tibia of three centimetres diameter, filled 
with cheesy material, a, Tuberculous focus 
in femur. (Nichols.) 



TUBERCULOUS DISEASE OE THE KNEE. 



149 



In tumor albus the most noticeable symptoms are heat, swelling, 
tenderness, and joint distention; while in hip disease, the joint being 
less accessible, a different class of symptoms, restriction of motion, 
limp, and distortions of the limb, are more to be depended upon. 





Xwr 




Fig. 142.— Right Knee-joint Bent. Sagittal section. Joint surface slightly separated, show- 
ing the infra-patellar fat pad, and the bursa under the patella tendon as well as the ex- 
tent of the joint synovial membrane. (Pick.) 

Swelling. — In tumor albus the knee will be seen to have lost its defi- 
nite contour, the depressions on the sides of the patella have become 
filled out so that there is an indistinctness of outline which is as per- 
ceptible to the touch as to the sight. Most often the patella seems to 
be raised from its position by a semi-solid mass and the whole knee 



i5o 



ORTHOPEDIC SURGERY. 



seems surrounded by a boggy infiltration. Later it assumes a spindle 
shape and the distention causes the skin to be somewhat anaemic in the 
more severe cases, whence the name of tumor albus. 

The swelling at the knee, unless suppurative synovitis is present to 
a marked degree, differs from that of synovitis with effusion, in that the 
swelling is of the bone and soft periarticular tissues, and is not alto- 
gether within the joint. If the 
effusion is large, as in chronic 
serous synovitis, the patella, 
when the muscles holding it are 
relaxed, can be depressed by 
pressing on it, and be felt to hit 
against the bone as it floats 
above the fluid within the joint. 
In effusion the shape of the 
swelling is characteristic. When 
effusion is the characteristic feat- 
ure, it is most prominent on both 
sides of the patella, and is lim- 
ited by the tendon of the quadri- 
ceps extensor muscle and by the 
ligament urn patellae. 

In some instances, one of the 
condyles — usually the internal 
condyle — is enlarged more than 
the other, causing knock-knee. 

Atrophy. — Atrophy of the 
muscles, both of the thigh and 
calf, is present, and reaches a seri- 
ous degree inacute cases. It is 
more equally distributed between 
the muscles of the thigh and those 
of the leg than in hip disease. 

Shortening. — Shortening is a 
much less important factor than 
in hip disease, and until late in the affection does not appear to any extent, 
and this late shortening comes as a result of the faster growth of the well 
leg oftener than as the out come of bone destruction. During the course 
of the disease lengthening of the affected leg may occur. The hyper- 
aemia occasioned by the inflammation induces the overgrowth in all 
directions of the tibial and femoral epiphyses, so that they outstrip for 
a while those of the other leg. In measuring a child with tumor albus 
it is, therefore, not uncommon to find the diseased leg half an inch 
longer than the other. Later in the disease, the trophic disturbance 




FIG. 143.— Tuberculous Knee in Adult. Gen- 
eral synovial tuberculosis. Large irregular 
area of tuberculous softening in epiphyseal 
end of femur, extending into joint along 
crucial ligaments. (Nichols.) 



TUBERCULOUS DISEASE OF THE KNEE. 



i;i 



which occurs in all these tuberculous joint affections makes itself felt 
and the diseased leg falls behind the well one in its growth. 

Pain. — The pain of the affection is, except during the acute exacer- 
bations, not severe, though pain on jarring the limb is common. Night 
cries are much less common than in hip disease, but they occur. 
When, however, the patient does suffer from an acute exacerbation, the 
pain and tenderness are excessive. From the exposed condition of the 



d~ 




FlG. 



[44.— Tuberculous Knee, Process of Repair Advanced. Small focus persists, a, Tibu 
b, tuberculous softening ; c, femur ; cf, patella. (Nichols ) 



joint jars and twists are very common, and the suffering may be ex- 
treme. Tenderness is very common, especially over the inner surface of 
the head of the tibia. In certain cases, however, the knee is held rigid 
by muscular spasm, and any reasonable manipulation fails to occasion 
any pain. 

Heat. — Heat of the affected joint is present and is a most valuable 
index of the progress of a case. It can be easily felt with the hand as 
long as the disease is active, but when it becomes quiescent it disappears, 
to return if anything goes wrong. It can be felt to diminish if treatment 



152 



ORTHOPEDIC SURGERY. 



\ 



is successful in quieting the condition of the joint, and is a most urgent 
indication for protective treatment so long as it exists in any degree. 

Lameness. — Lameness is a constant symptom. It varies with the 
sensitiveness of the joint and is much influenced by the amount of flexion 
present in the diseased knee. 

Muscular Fixation. — Muscular fixation is a symptom of this as of all 
chronic tuberculous ostitis, but is less prominent than in the hip. In 

the early stages it may be 
practically absent. The joint 
may be held perfectly rigid 
in full extension or in partial 
flexion, or a certain arc of mo- 
tion may be permitted, and 
then the muscles quickly 
catch the joint and prevent it 
from going farther. Persis- 
tent muscular spasm results 
in the characteristic malposi- 
tions of the affection : flexion, 
and subluxation of the tibia. 
Deformity . — Malpositions 
of the limb result from the 
greater power the flexor mus- 
cles of the thigh possess in 
contrast to the extensors. 
The limb becomes gradually 
flexed almost from the first, 
and if the affection goes on 
without treatment, flexion 
may reach a right angle, and 
this is the tendency of the 
disease throughout and a 
marked obstacle to its suc- 
cessful treatment. 

Even when the affection 
is nearly cured or after a 
slight injury of the joint 
flexion may return, which is 
accompanied by increased heat and tenderness. Together with the 
flexion, and as a result also of the predominance of the flexor 
muscles of the thigh, subluxation of the tibia backward occurs at a 
later stage of the affection ; this is due to the shape of the joint sur- 
faces and the persistent contraction of the hamstring muscles always 
pulling the tibia backward. If the leg has assumed this distortion 



v 




Fig. 145.— Bony Ankylosis of the Knee-joint, with 
Ankylosis of Patella. 



TUBERCULOUS DISEASE OE THE KNEE. 



153 



and is straightened without an attempt to correct the subluxation, the 
tibia will lie in a plane back of that of the femur, and the part of the 
knee formed by the femur and patella will be unduly prominent. 




FIG. 146. — Subluxation in Tumor Albus. 



Another result of long-continued muscular spasm is the external 
rotation of the tibia upon the femur, which accompanies severe grades 
of flexion and persists after straightenin 



_, of the leg if such is accom- 




FlG. 



-Position of Deformity in Tumor Albus. 



plished. In the same way a certain amount of knock-knee is apt to be 
present in the corrected limb after severe grades of tumor albus. 

Abscess. — Abscess appears either as a purulent distention of the cap- 



154 



ORTHOPEDIC SURGERY. 



sule, which may point at any part of the surface and discharge by sinuses 
for an indefinite time, or abscesses form in the periarticular tissues as 
in hip disease. As a rule abscess formation is accompanied by an acute 
degree of the affection. 

DIAGNOSIS. 

The diagnostic symptoms and signs in tumor albus are an intermit- 
tent lameness; a general enlargement of the knee-joint, with a feeling 

of stiffness and pain on using the limb ; 
heat over the joint; and the presence 
of local tenderness and muscular stiff- 
ness in manipulation of the joint. 

The character of the enlargement of 
the knee-joint is of great importance. 

DIFFERENTIAL DIAGNOSIS. 

Gross errors in diagnosis in affec- 
tions of the knee are not common, as a 
thorough examination of the joint is 
readily made. The distinction between 
a synovitis with effusion and a chronic 
ostitis is based on the size and shape of 
the swelling. The diagnosis is often 
aided by an ,r-ray examination. By 
the test of aspiration and guinea-pig 
inoculation, a diagnosis can be estab- 
lished. 

Synovitis. — Sluggish cases of syno- 
vitis in young children should be re- 
garded with very great suspicion, inas- 
much as they are likely to eventuate 
in tumor albus at any time, if the con- 
dition is not already that. 

Periarticular Disease. — Periarticular 
disease (inflammation of bursae and 
periarticular abscesses) is to be distin- 
guished from true articular disease in 
that there is little or no joint stiffness, 
and in that the swelling, if present, 
does not bear the relation to the patella 
that occurs when there is fluid beneath the patella ; the distention be- 
ing clearly outside of the joint sac. 

Functional disease (hysterical, neuromimetic) of the knee is to be 
recognized by the absence of objective symptoms and the prominence 




FIG. 148.— Tuberculosis of Right Knee 
joint, with Marked Hony Enlarge- 
ment at Inner Side of Knee. 



TUBERCULOUS DISEASE OF THE KNEE. 



I s 



3 : 



of subjective symptoms. Heat is generally absent, limitation of motion 
and tenderness may be excessive, and swelling and alteration of the 
joint contour are absent. 

Arthritis Deformans. — A diagnosis between a tuberculous affection 




Fig. 149. — Severe Tuberculosis of Knee-joint with Marked Swelling - , Flexion, and Sinus. 

and that form of arthritis deformans with synovial infiltration and 
change is difficult and can often be made only by a careful study of the 
case with the aid of the inoculation test. It is to be remembered 




Fig. 150. — Tuberculosis of Knee-joint with Extreme Flexion Deformity. 

that tuberculous disease is more common in childhood than is arthritis 
deformans. 

Haemophilia may cause an inflammation of the knee closely resem- 
bling tumor albus. The diagnosis must be made by establishing the 
existence of the bleeder's diathesis and by the course of the case. 



156 ORTHOPEDIC SURGERY. 

PROGNOSIS. 

The prognosis of tumor albus is similar to that of the same affec- 
tions of the other large joints. The functional results after conserva- 
tive treatment are in average cases excellent ; sometimes perfect motion 
is restored, but in general only an incomplete arc. remains with occa- 
sionally complete rigidity. The earlier that treatment is begun and the 
more faithfully it is carried out, the better is the outlook as to functional 
result. In advanced cases disability necessarily follows, and in neglected 
cases deformity of the limb, flexion at the knee, subluxation of the tibia, 
and the formation and discharge of abscesses are likely to occur, ending 




FlG. 151.— Old Tumor Albus Recovered, Showing Degree of Possible Flexion. 

either in a complete destruction of the joint or in a cure with ankylosis. 
A liability of the dissemination of the tuberculous disease to the brain 
or lungs exists in this as in other similar affections. 

In all severe cases there is a danger of permanent distortion of the 
limb. This may be so severe as to render the limb useless. Flexion of 
the limb is a constant result in severe cases unless treated with great 
care. Shortening is less likely to exist to a troublesome extent than in 
hip disease. 

As in all cases of epiphyseal ostitis of the larger joints, the progno- 
sis as to the time of requisite treatment depends not only on the time 
needed to check the inflammation, but also for the re-establishment of 
sound bone tissue capable of bearing weight without danger of relapse. 
This in growing children demands a long time. Protection is generally 



TUBERCULOUS DISEASE OF THE KNEE. 



D/ 



necessary for from one to two years, and perhaps even longer, after the 
acute stage is ended. 

TREATMENT. 

The treatment may be classed as conservative and operative. 

Conservative Treatment of Tumor Albus. 
What was said in regard to the treatment of hip disease may be 




FIG. 152.— Old Tumor Albus Recovered with Motion, Showing Subluxation of Tibia. 

repeated in speaking of epiphysitis of the knee-joint. The treatment 
should be thorough and persistent, and should meet the indications, and 
fixation and protection are the most important indications in diseases of 
the knee, while traction is less so. The employment of protection 
should be continued until it is probable that the epiphysis is normal, 
which is a matter of judgment in every case. Protection should be dis- 
continued gradually and tentatively ; if discontinued too soon, recur- 
rence will take place, or the deformity of the limb will increase. Fixation 
should be used so long as there is any activity of the inflammation ; this is 



i 5 8 



ORTHOPEDIC SURGERY 



indicated by pain, muscular spasm, or tenderness. Efficient fixation of 
the knee does not require confinement to bed except in very acute cases, 
in abscess, and in deformity. 

In cases in the acutest stage the patient is kept in bed with the limb 
held by weight and pulley traction and the foot and limb steadied by 
sand bags or side splints or by a splint plaster bandage. Ordinarily 
this acute stage is absent or is brief, and ambulatory treatment is both 
possible and desirable. 

Fixation. — It is manifest that the most thorough fixation is made if 
the fixing appliance is as long and extends as high as possible. The 

leg and femur, if much longer 
than the appliance, will have 
a greater mechanical advantage 
than if the splints are suffi- 
ciently long. It should also be 
borne in mind that, owing to 
the fact that the thigh is well 
covered by soft tissues, a cer- 
tain amount of motion is pos- 
sible owing to the yielding of 
the soft parts. Fixation by stiff 
bandages is an efficient method 
of treatment when the bandages 
are properly applied. They 
should reach from the groin to 
the ankle, in the acute cases in- 
cluding the foot, and as firmly 
as possible grasp the muscles of 
the limb. Plaster of Paris is the 
most available material for use. 
The method does not give in 
all cases certain, definite sup- 
port. Judson says in regard to 
it : "It may be an exaggeration, 
but it conveys the idea, to say 
that a plaster-of-Paris or silicate 
splint, applied to the leg and thigh, contains a mass of jelly in which 
the femur is but little restrained from motion." And in a degree this 
is true of all stiff bandages. 

The figure shows the inefficiency of a loosely applied plaster band- 
age so far as fixation is concerned. Other stiff bandages are of silicate 
of potash, leather, celluloid, wood pulp, papier mache, etc. They may 
be cut down the front and laced so as to be removed at any time. Fix- 
ation without protection is inadequate treatment when locomotion is 




Fig. 



[53. — Tuberculosis of Knee-joint with 
Abscess. 



TUBERCULOUS DISEASE OE THE KNEE. 



159 



desired. For this reason it is insufficient to apply a stiff splint to the 
affected leg and to allow the patient to walk without further protection 
of the limb. 

Fixation as a means of treatment so far has been considered only 
as applicable to the limb in its straight position. Much more often a 




Fig. 154.— Radiograph of Old Tuberculosis of Knee-joint, Showing Destruction of Joint Sur- 
faces and Bone, Flexion and Subluxation of Tibia. 

degree of flexion is present to complicate matters, the treatment of 
which will be considered later. 

Protection. — Protection can be furnished by means of crutches and 
raising the sound limb by a thick sole which allows the affected limb to 
swing clear of the ground. Better protection is furnished by means of 
a splint with perineal support and longer than the limb, which passes 
below the foot so as to take the jar of locomotion. The best of these 
splints is one similar to that already described as a protective splint in 
hip disease. It will be described more fully in speaking of the treat- 
ment of flexion in tumor albus. 

Thomas Knee Splint. — A simple appliance is the Thomas knee splint 



i6o 



ORTHOPEDIC SURGERY. 



(Chapter XXL, 14) which consists of a padded iron ring fitted so as to 
surround the thigh at the perineum, and fastened to two rods on each 
side of the limb, longer than the limb and secured at the bottom to a 
metal plate below the foot or bent to fit into a slot under the shank of 
the boot. 

The bar at the bottom of the splint can be utilized as a means for 
using traction if adhesive plaster is applied to the leg and webbing- 
sewn to the lower ends; the webbing straps are buckled tightly around 
the bar, and a certain amount of traction can be exerted. The idea of 





Fig. 



155.— Imperfect Fixation of Knee-joint 
bv Loose Plaster Bandage. 



FIG. 156.— Imperfect Fixation of Knee-joint 
by Plaster Bandage of Improper Length. 



using traction is not in accordance with the views of the inventor of 
the splint. The leg can be fixed by means of bandages and leather 
bands attached to the splint. With this splint applied, the patient sits 
in a ring supporting the perineum, while uprights run below the foot and 
bear the body weight. 

In cases requiring less rigid protection and in the case of adults the 
inner half of the perineal ring is cut away and from the two extremities 
of the cut ring is slung a leather perineal band on which the patient 
rests in the same manner as in a hip splint. 

In acute cases and cases tending to flexion the use of a plaster-of- 
Paris splint in addition to the Thomas splint is desirable, as better fixa- 
tion is secured than by bandages. Traction is necessary only in very 



TUBERCULOUS DISEASE OF THE KNEE. 



161 



acute cases ; a stiff bandage to the knee in addition to the Thomas splint 
contributes better fixation than is possible with the splint alone. 

The Thomas splint is slung from the shoulder by means of a strap, 
and the well limb is raised by means of a cork, wooden, or steel patten. 
Crutches are not necessary in connection with the Thomas splint. 

Calliper Splint. — When the condition of the limb has improved so 
much that spasm and sensitiveness are absent or in mild cases the 
Thomas splint (Chapter XXI., 15) can be shortened and the ends 
slotted into the sole of the shoe at such a place that the splint is too 
long for the heel to touch the ground, and in this way the patient walks 
about suspended largely by the perineal ring and bearing but little 




FlG. 157.— Wire Splint for Gradual Correction of Knee Flexion. 

weight on the diseased joint. Then gradually after some months the 
use of the splint may be discontinued. 

When convalescence has been further established and protected 
motion at the joint is possible, the knee splint may be jointed with a 
spring catch and check to limit the amount of motion. 

Blisters, cauterization, and counter-irritation are beneficial only in 
relieving the symptoms of pain temporarily. 

The treatment by passive hyperemia and dry heat is useful if at all 
in the milder and more chronic cases. 

Treatment of Complications.— Deformity. — Flexion of the knee is 
commonly seen even in the early stage of the affection, associated in 
the early part of the disease with an acutely sensitive condition of the 
11 



! 



l62 



ORTHOPEDIC SURGERY. 



A. 



joint, but later in the history it may come on insidiously and without 
pain. 

The means of straightening a knee-joint flexed by acute disease may 
be classified as follows : 

I. By traction in- the line of the deformity applied (a) in bed; (b) 
while the patient goes about. 

2 By simple fixation by means of a succession of plaster-of -Paris 
bandages. 

3. By straightening under ether. 

1 (a). In sensitive cases it may be necessary to confine the patient 
to bed. Traction by weight and pulley can be applied to the leg by 
means of adhesive plaster applied below the knee, 
the leg being supported by a firm cushion under 
the knee arranged so that traction comes in the 
line of the deformity. After a diminution of the 
spasm, which follows very soon upon the appli- 
cation of traction, the limb can be made straight 
gradually and fixed in a straightened position, and 
ambulatory treatment can be begun. 

1 (&). Traction in the line of the deformity 
can be applied to the limb while the patient 
goes about, by one of several appliances which 
are more or less expensive. The best splint is 
one already alluded to, similar to the protection 
splint described for hip disease (Chapter XXL, 
16). 1 It is furnished with a perineal band which 
takes the body weight off of the leg, and at the 
knee is a lock joint which can be set at any angle. 
The bottom of the splint goes far enough below 
the foot to protect the limb from jar in walking, 
and ends in a traction bar. The splint is set at 
an angle corresponding to the angular deformity 
of the affected knee, and traction is made up- 
ward above the knee by means of adhesive plaster 
attached to the thigh and buckling on to the 
splint, and extension is made downward below 
the knee by a plaster extension pulling down 
to the traction bar at the bottom of the splint. 
The leg is fixed in the splint by leather lacings for the thighs and calf, 
which are adjusted after the extension is tightened. A simpler appa- 
ratus has been described, 2 made of plaster of Paris and serving the same 
purpose except that it does not allow weight bearing on the affected leg. 

1 Lovett : Orth. Trans., vol. vi. 

2 H. L. Taylor: Orth. Trans., vol. vii., p. 53. 



FIG. 158.— Thomas Cal- 
liper Splint, with Pads, 
Applied. (Ridlon and 
Jones ) 



TUBERCULOUS DISEASE OE THE KNEE. 163 

2. Reduction of Flexion by Fixation Bandages. — A very simple way 
to straighten a knee-joint acutely flexed by disease, when apparatus 
cannot be afforded or is impracticable, is by simple fixation of the knee- 
joint by means of a series of plaster-of-Paris bandages. These should 
be applied to the knee in its deformed position without any attempt to 
extend it. It will be often found in the lighter cases that the limb can 
be made straighter at each successive bandage, so great is the sedative 
action of complete fixation. It is hardly necessary to add that no 
weight should be borne upon the limb during the process of straighten- 
ing. 

3. Forcible Reduction of Flexion. — In cases without adhesions the 
knee is easily put in a correct position with the use of little or no force 




Fig. 159.— Reduction of Flexion Deformity by Traction in Recumbency. 

under complete anaesthesia. If the leg is allowed to remain in the 
flexed position, angular ankylosis will probably occur, as shown in the 
figures. When firm adhesions have been formed at the knee-joint, cor- 
rection by means of appliances will be found tedious, painful, and some- 
times impossible, and generally forcible correction of some sort will be 
necessary to break down the adhesions. One way is to break down the 
adhesions by forcibly flexing the leg, and then by forcible extension to 
straighten it. The danger of rupturing the popliteal artery, which has 
occurred, is in this way diminished. Many appliances ha\ r e been 
devised to give greater power in forcible correction. One procedure 
not requiring the use of apparatus is as follows : The patient is placed 
upon the floor upon the back and the surgeon stands over the patient, 
holding the flexed knee with both hands, the fingers being placed 



164 



ORTHOPEDIC SURGERY. 



under the popliteal space. The whole weight of the surgeon's trunk 
can be thrown upon the end of the lever furnished by the patient's leg, 
the hands of the surgeon, pulling upon the popliteal space, furnishing 
resistance. After the limb has yielded and the adhesions are broken, 

it can be straightened if the pa- 
tient is turned upon the face ; a 
downward force being applied to 
the heel, resistance being fur- 
nished by a cushion placed under 
the patient's knee. When sub- 
luxation of the tibia is present 
it must be corrected. This can- 
not be done so well by this 
method as by the instrumental 
method to be described. After 




Fig. 160.- 



-Jointed Traction Knee Splint 
Applied. 




-Goldthwait's 

Applied. 



Genuclast 



correction, the limb should be well surrounded with sheet wadding and 
a stiff bandage applied, the limb being held straight until the plaster 
has become hard. The procedure is sometimes followed by pain, and 
opiates may be necessary for a few days. Such measures are not 
required except in resistant cases. The dangers incurred by this pro- 



TUBERCULOUS DISEASE OE THE KNEE. 165 

ceciure are not so great as would be supposed. The danger of rupture 
of the artery can be avoided by care. Separation of the epiphysis of 
the femur may take place, but is cured by the fixation requisite to treat- 
ment, and should not occur if the force is carefully applied. Fracture 
of the femur and tibia can be avoided by care. 

If the deformity, flexion, remains uncorrected in severe ostitis of the 
knee-joint, a subluxation of the tibia backward takes place, due to 
the contraction of the hamstring muscles. This is due in part to the 
spasm of the hamstring muscles, which have pulled the tibia backward, 
but chiefly to the fact that owing to adhesions the flexed tibia is unable 
to slide forward over the condyles of the femur, as happens in normal 
extension. Attempts to straighten the leg simply crowd the anterior 
edge of the tibia into the condyles. To obviate this the head of the 
tibia should be pressed forward and upward to the same degree that the 
leg is raised. 

The most efficient method of accomplishing this is by the use of the 
apparatus shown in the figure called by Goldthwait, 1 who modified it 
from the original apparatus, the "genuclast." 

Pressure forward on the head of the tibia is exerted by turning the 
handle ; this, by means of a screw force, pushes a plate forward against 
the tibia, working through a band. The calf muscles protect the artery 
and nerve from injurious pressure. Counter-pressure is secured by 
means of leather straps, which are passed respectively over the knee 
and leg, protected by a thick layer of saddler's felt. Several straps 
will be needed at the knee to prevent loss of counter-pressure, as the 
limb is made straighter. Another strap, under the leg, secures the 
lower part of the leg. The side bars, bands, and plate of the apparatus 
should be of strong steel. 

The apparatus is put on the limb in a flexed position (after ruptur- 
ing adhesions by forcible flexion if that is needed), the head of the tibia 
is pushed forward as far as is advisable, and, by means of the end of 
the appliance, which serves as a handle, the leg is extended ; the press- 
ure forward of the head of the tibia can be increased, and the counter- 
pressure regulated if necessary, by loosening such of the straps as 
extension of the limb may tighten too much. In some cases the reduc- 
tion may be accomplished at one time, while in others successive appli- 
cations of the apparatus are necessary. Adhesions of the patella to 
the front of the femur may constitute an obstacle to reduction without 
cutting. The treatment of cases resisting this method will be consid- 
ered in the section of this chapter on operative treatment. 

Experiments on the cadaver which were conducted by one of the 
writers at the Harvard Medical School, through the courtesy of Drs. 
C. B. Porter and T. Dwight, showed that by means of this appliance 
Boston Med. and Surg. Jour.. September 7th. 1893. 



1 66 ORTHOPEDIC SURGERY. 

the tibia could readily be pushed forward to any desired extent. On 
normal joints, the tibia can be pushed forward to a considerable dis- 
tance without rupturing the ligaments. 

In general, correction of flexion deformity under ether is the best 
method except in slight cases. 

Abscess. — The treatment of abscess is the same that is recom- 
mended for the treatment of abscesses at the hip, except that they are 
generally more superficial and can be opened earlier. They do not 
dissect about between the muscles to the extent that hip abscesses 
often do. 

Operative Treatment of Tumor Albus. 

The operative measures to be considered are : 

1. Excision. 

2. Arthrectomy and erasion. 

3. Amputation of the leg. 

1. Excision of the knee-joint is to be undertaken in those cases in 
which conservative treatment has failed to arrest the progress of the 
disease ; in which originally the disease is too extensive to warrant con- 
servative treatment ; in which the general health is failing and the dis- 
ease failing to improve under efficient conservative measures. In 
adults it is to be undertaken earlier than in children, as the progress of 
the disease is in the former less favorable than in the latter. 

Excision is inferior to conservatism as a treatment of knee-joint 
disease in children, because the functional results are not so good. 

Excision of the knee is also performed to correct the deformity 
caused by bony ankylosis at an angle of flexion. 

It would be fair to assert that in patients between five and twenty, 
the mortality from the operation, near and remote, would not be far 
from ten per cent, being less rather than more than this percentage. 

The functional results after excision are, however, inferior to the 
results after conservative treatment. Ankylosis is to be hoped for after 
excision and is complicated by a tendency to flexion of the apparently 
ankylosed joint. 

It may be said with regard to the amount of shortening after excis- 
ion in cases in which the epiphyseal lines are saved that it is likely to 
be only moderate, although even then it is more than after conservative 
treatment. 1 

Operation. — The operation of excision of the knee-joint is per- 
formed as follows : 

The leg should be carefully prepared for an aseptic operation. The 
use of the Esmarch bandage and tourniquet is advisable. The joint is 
opened by a free anterior incision passing from the inner to the outer 
1 Arch. f. klin. Chir., 1885, iv., 32. 



TUBERCULOUS DISEASE OE THE KNEE. 



167 



side of the joint slightly below the patella, the ligamentum patellae is 
divided, the periosteum and muscular attachments are cleared from the 
ends of the bones, the ligaments are cut, and the articular end of the 
femur protruded through the incision and as much as seems desirable 
sawed off. In the same way the tibia is cleared and protruded as a 
safeguard against injuring the popliteal vessels. The patella should be 
removed if it is diseased. 

In children it is desirable to avoid removing bone below the line of 
the epiphysis — a precaution not necessary in adults. It is best at first 
to remove a very thin section, just enough 
to take all the articular surface of both 
bones, and then to remove another section 
if the disease is very extensive, or if only 
foci of disease are seen to scoop them out 
extensively with a sharp spoon. 

It is of the utmost importance to at- 
tend carefully to the plane of section which 
the saw makes in removing the articular 
surfaces. If these planes are ever so 
slightly oblique, the whole axis of the limb 
is distorted and the line of weight-bearing 
is wrong and tends to cause angular de- 
formity at the knee. In the femur the 
plane of section should be parallel to the 
articular surface and not perpendicular to 
the shaft of the bone, which would make 
it oblique at the joint. As soon as sec- 
tion of the bones has been made, the 
new surfaces should be placed in con- 
tact and the line of the limb carefully ob- 
served. 

To secure fixation the bones may 
be wired together or fastened to each 
other by wire nails or pegs of ivory or bone. A wire posterior splint 
may be used, but, in general, a plaster-of-Paris bandage reinforced 
by a steel bar and with a window cut for dressing, the bandage includ- 
ing the foot, furnishes the best means of fixation, the bones having been 
fixed accurately in position by some of the means mentioned and the 
limb after that handled very carefully. The only objection to it is that 
in the profuse discharge of serum which takes place necessarily from 
so large a wound within the first twenty-four hours, the plaster is likely 
to be stained through and may have to be changed. But if a suffi- 
ciently heavy dressing is put on, this will ordinarily not happen to any 
extent, or if it does a light dressing can be applied outside to protect 




FIG. 162.— Osteotomy for Deform- 
ity with Ankylosis. (After 
Hoffa.) 



1 68 ORTHOPEDIC SURGERY. 

the stained spot. Occasionally the plan is useful to dress the limb 
after operation in a heavy dressing and on the next day to redress it 
and apply the plaster. In this way one may be almost sure of a dress- 
ing which can be left on almost indefinitely, provided the operation has 
been aseptic. 

There are two precautions to be observed in putting the leg up in 
splints or in plaster: first, the tendency to eversion ; and second, the 
tendency to dropping backward of the head of the tibia. With moder- 
ate precautions these deformities may be avoided. When the bones 
are wired together, if the holes which are bored in the tibia for the 
insertion of the wire are placed well backward and the corresponding 
holes in the femur well forward, much will be done to counteract this 
backward displacement of the leg upon the thigh. 

A protection splint is to be worn for some time to prevent the recur- 
rence of flexion. It is much the wiser course to have the patient wear 
a perineal crutch (in the form of a Thomas knee-splint), which shall 
prevent bearing any weight on the leg until several months after oper- 
ation. If this precaution is neglected, permanent flexion of the limb is 
likely to occur or a lighting up of the original disease. 

Excision of the Knee for Angular Ankylosis When excision of 

the knee is done for angular ankylosis, the only modification of the 
operation which is necessary is the removal of a wedge of bone large 
enough to allow the ends of the bone to come together, so that the 
angularity is obliterated. 

Osteotomy of the femur is a measure which may be used to correct 
flexion deformity at the knee too strong to be overcome by forcible 
straightening. The osteotomy should be linear and as near the joint 
epiphyseal line as possible. This can be employed in place of a wedge- 
shaped excision for angular deformity, as not involving shortening. 
The osteotomy is followed by careful straightening of the limb. The 
advantage of this method lies in the fact that any motion remaining 
at the joint is not destroyed as it must be in excision. Its disadvan- 
tage is that the condyles of the femur are necessarily displaced for- 
ward to form an angle with the shaft. A linear or wedge-shaped oste- 
otomy of the upper part of the tibia has been described by Kbnig for 
the same purpose. 

2. Arthrectomy.— As a substitute for excision, what has been 
termed arthrectomy or erasion has been employed. 

Arthrectomy consists of the removal of all palpable and obvious 
portions of diseased tissue, whether in the synovial membrane or else- 
where, leaving what appears to be healthy tissue. Two advantages are 
claimed for this operation over excision: (i) That it does not interfere 
with the growth of the limb, and (2) that mobility of the joint may be 
preserved. It may be added that the latter is an exceptional event and 



TUBERCULOUS DISEASE OF THE KNEE. 169 

not altogether so desirable or safe an ending under the circumstances 
as bony ankylosis. The objection to the operation is that it is not 
thorough, and oftener than excision fails to eradicate the disease. 

The operation offers advantage over excision only in the case of chil- 
dren and chiefly before the disease has made extensive progress. It is 
easy to see that, if any extensive disease of the bone is present, any 
measure short of thorough removal must necessarily fail. The opera- 
tion is, therefore, not suited to cases in which there are many sinuses 
and bone enlargement, but to milder cases as a less severe operation 
than formal excision. 

In the matter of risk there is little to choose between this operation 
and excision, for the immediate death rate under proper precautions 
is very small in both operations. The risk of operative tuberculous in- 
fection, alluded to so often in speaking of operations upon tuberculous 
joints, is present in arthrectomy as in excisions. 

Operation. — The operation itself may be described as follows : The 
joint is opened as in cases of excision and the tuberculous synovial mem- 
brane as far as possible should be dissected out ; if diseased spots are 
found in the bone or have been previously located by the-r-ray, these foci 
should be removed by the curette or chisel, and the cavity left in the bone 
wiped out with pure carbolic acid and alcohol, and the joint sewed up 
or drained according to the extent of the disease and the general aspect 
of the case. If the whole epiphysis is diseased, excision is of course 
unavoidable. Instances of excellent recovery with complete healing 
occur after this operation, and success has followed the procedure in 
many cases in the practice of the writers. The most thorough removal 
possible of all tuberculous tissue in the affected joint is essential, neces- 
sitating sometimes complete dissection and removal of all of the syno- 
vial membrane, as well as careful curetting of the bone. The patella 
should be removed or left, according to its condition. 

The parts of the knee-joint to be most carefully investigated for 
diseased foci are the synovial pockets and the epiphyseal lines of the 
femur and tibia at their lateral aspects. Here one may find foci of tu- 
berculous material extending into the epiphysis, without, however, in 
most cases crossing the epiphyseal lines. 

The after-treatment should be like that of excision, except that wir- 
ing or nailing the bones together is not necessary, as the ligaments 
should be preserved so far as possible. 

Flexion of the limb may follow arthrectomy as well as excision ] in 
cases in which protection to the joint has been discontinued too early, 
so that the after-treatment should be as careful and as prolonged as 
after excision of the joint. 

3. Amputation. — In cases of extreme disease of the knee-joint 
! Hofmeister : Abst. in Arch. f. Orth , i.. 2. 



170 ORTHOPEDIC SURGERY. 

amputation of the thigh is necessary as a life-saving measure. As for 
the indications determining a choice between excision and amputation, 
it can be said that when the patient's reparative power is slight an am- 
putation is to be preferred. The question is largely one of individual 
judgment; if excision is first tried and fails to arrest the disease, and 
finally amputation has to be performed, the patient's chances are, of 
course, injured by the choice of excision in the first place. In the adult 
extensive removal of the bones may be accomplished by excision with- 
out any danger of arrest of growth, and few patients can be brought to 
consent to amputation of a limb so long as any other method of treat- 
ment holds out the faintest prospect of relief. In children amputation 
should be deferred to the last moment and excision given the prefer- 
ence, unless the eradication of the disease would necessitate the re- 
moval of so much bone that a useless leg would result from that. 

In children, therefore, the operation could be advised only when the 
joint was hopelessly disorganized and so much of the shaft of the long 
bones was evidently diseased that an excision was not practicable. 

Summary. 

The treatment of tumor albus should consist in fixation of the dis- 
eased joint by plaster of Paris or some suitable splint, with traction in 
cases in which the muscular spasm is very marked. If ambulatory 
treatment is to be undertaken (which is almost invariably to be advised), 
protection is also necessary. This is furnished by the Thomas splint, 
a high shoe, and crutches, or by the use of a protection splint similar 
to the one used in hip disease, etc. Fixation can be discontinued at 
the close of the acute stage, but protection is advisable for a much 
longer time. 

Excision is not in children an advisable method of treatment until 
mechanical measures have proved inefficient after a faithful trial, and 
the same is true of arthrectomy. The latter is not suitable for adults. 
Deformities should be corrected as they arise. 



CHAPTER V. 

TUBERCULOUS DISEASE OF THE ANKLE AND 
OTHER JOINTS. 

ANKLE. 

Ankle (Symptoms. — Diagnosis — Prognosis. — Treatment). — Shoulder (Symp- 
toms. — Treatment). — Elbow (Symptoms. — Treatment). — Wrist (Symptoms. — 
Treatment). — Sacro-iliac disease (Etiology. — Symptoms. — Diagnosis. — 
Prognosis. — Treatment). 

The seat of the disease may be in the articular end of the tibia or 
in the astragulus ; and other adjacent bones may be involved secondarily 
or independently, as the os calcis, the scaphoid, cuboid, and cuneiform 
bones. The pathological process does not differ from that already 
described, but on account of the numerous synovial sacs in the tarsus 
and the proximity of the bones to each other, extension of the disease 
is favored. 

Symptoms. — Pain and tenderness of the whole joint to pressure and 
motion may or may not be present. Tenderness, as a rule, is present 
over the joint capsule in front, and perhaps under the malleoli, and 
swelling and heat are invariable accompaniments of the affection. Mus- 
cular rigidity is marked in most cases. 

Lameness is an early and a marked symptom. Sometimes it is pro- 
duced by the pain which weight-bearing causes in walking, but more 
often by the muscular stiffness which will not allow the ankle-joint to 
bend. The swelling consists of a boggy infiltration of the soft parts 
around the ankle, along with a distention of the joint capsule by gelati- 
nous granulations. In character it is cedematous. This swelling is 
uniform around the ankle, except when an abscess is pointing on one 
side. The depressions in the contour of the ankle in front and behind 
the malleoli disappear in the swelling. The foot in affections of the 
ankle-joint usually assumes a position with the toes pointing downward, 
and in chronic cases with the foot slightly rolled outward (in the posi- 
tion of equino-valgus). This, however, is not the only malposition, for 
the foot may assume the position of pure talipes calcaneus. These 
malpositions are brought about by the abnormal tonic muscular contrac- 
tion, and these deformities yield of themselves and the foot returns to 
its normal position when the irritation is quieted in the joint by proper 
treatment. 

171 



172 



ORTHOPEDIC SURGERY. 



Wasting of the thigh and calf muscles occurs. Abscesses may occur. 

When the disease attacks the medio-tarsal or tarso-metatarsal joints, 

the anterior part of the instep appears swollen and is hot and tender. 

b 




FIG. 163. — Tuberculous Ankle-joint. Diffuse tuberculosis of tarsus. Primary focus lost in 
the area of destruction, a, Tuberculous infiltration of soft parts; b, tuberculous soften- 
ing of tarsal bones. (Nichols.) 

Motion at the ankle is but little restricted, but motion in the anterior 
part of the foot is attended by pain and is usually lost. The location 
of the affection is evident from examination. If the os calcis is attacked 




FlG. 164.— Tuberculous Ankle, a, Lower end of tibia; b, tuberculous cavity in tibia; c T 
tuberculous disease of calcis ; d, tuberculous disease of astragalus. (Nichols.) 

primarily it is manifested by the same symptoms of local inflammation 
without any symptoms referable to the ankle-joint. 

The recognition of disease of the ankle is dependent on the symp- 
toms given above. 



TUBERCULOUS DISEASE OE THE ANKLE. 



173 



Diagnosis. — The most troublesome affections to diagnosticate from 
ankle-joint disease are the functional affections which result often from 
sprains and injuries. Here it is not uncommon to find, in hypersensi- 
tive women chiefly, a limitation of motion of the ankle, with much pain 
on manipulation and pressure ; there ma)' be swelling left over from the 
injury, and the question to be decided is whether any disease of the 
joint exists which can well be made worse if the patient goes about, or 
if it is a disturbance of circulation and innervation which can be over- 
come by judicious management. In one case rest is indicated, in the 
other activity. The diagnosis of functional joint disease is considered 
in full in the proper place. 

One must depend chiefly upon the existence of the objective signs 
of ankle disease, rather than upon the patient's feelings; allowing, 
however, due weight to the history 
of the affection and the patient's 
sex and constitution. 

Inflammatory flat-foot may at 
times present symptoms similar to 
those of ankle-joint disease. Rest 
and measures to quiet the process 
will quickly control the symptoms 
in flat-foot but not in tuberculosis. 

The .r-rav is of value in estab- 



ishing the diagnosis. 




-Ankle-joint Disease at an Eai 
Stag-e. 



Prognosis. — Unless the disease 
is advanced, children who are in 
good condition as a rule make good 
progress under conservative treat- 
ment. The prognosis is somewhat 
better when parts other than the 
astragalo-tibial joint are affected. 
The prognosis in adults under con- 
servative treatment is less favorable. 

Mechanical Treatment. — Protection from jar is indicated, as well as 
fixation of the joint — as will be readily seen if it be borne in mind that 
in locomotion the whole weight of the body is borne at each step upon 
the comparatively small surface of the upper articulating portion of the 
astragalus. Fixation of the ankle in a stiff bandage, while allowing the 
patient to walk upon the limb, is a manifest error, as affording little or 
no real protection to the joint. Fixation is of advantage in the more 
acute stages of the affection, and is readily furnished by means of stiff 
bandages. A plaster-of-Paris bandage is the most convenient appliance, 
and should be carried above the knee so as to fix that joint also. A 
fixation ankle brace (Chapter XXI., 17) may be used instead of the 



74 



ORTHOPEDIC SURGERY 



plaster-of-Paris bandage. Protection can be furnished either by means 
of crutches or, more thoroughly, by means of protective splints with 
perineal supports described for the knee-joint. The Thomas knee-splint 
is one form available (Chapter XXI., 14). 

Such apparatus for fixation and protection should be worn through 
the acute stage of the disease. If abscesses form they should be in- 
cised and traced to their source, and if loose bone is detected this 
should be removed. If the foot assumes a malposition, this should be 
corrected ; this is best done by applying a plaster bandage to the foot 
in its malposition and quieting thereby the inflammation so much that 




FlG. 166.— Tuberculous Ankle. Advanced Stage. 



in two weeks the malposition will be found less and an improved posi- 
tion can be gained. Bier's congestive treatment is applicable in cases 
of tuberculosis of the ankle. The general health should be carefully 
inquired into and appropriately treated. All these procedures may be 
grouped together and be said to complete the expectant method of 
treatment. 1 

The conservative plan fully carried out is justifiable in a large pro- 
portion of cases, and on the whole the results obtained are good. In 
cases of tuberculous disease of the ankle where the progress is not sat- 
isfactory, the decision of continuance of conservative treatment or the 
adoption of operative interference is one which is based largely upon 
the patient's age and the circumstances of attendant care. 

1 N. Y. Med. Rec, August 21st, 1880, p. 197 ; Am. Jour, of Obstet., 1880, p. 
434- 



TUBERCULOUS DISEASE OF THE ANKLE. 



/b 



Operative Treatment. — There are three alternatives left if the ex- 
pectant method fails. The mildest form of operative interference con- 
sists in curetting the sinuses and removing" what diseased bone it is 
possible to reach. Occasionally it maybe possible to scrape out a focus 
of tuberculous material in the os calcis, but in the tarsus proper it is 
rarely a satisfactory procedure. The second operation is a formal ex- 
cision of the diseased bones. The third and 
most radical measure is amputation of the 
leg or foot. 

The question arises, Will the disease in 
the foot cease if the bone is removed ? It 
may be said that, if thoroughly removed in 
children, relapse is unlikely to occur. More 
relapses occur from partial operations and 
from gougings and scrapings than from any 
other cause. The earlier excision is done and 
the more thoroughly the diseased bone is 
removed from the tarsus, the better is the 
result. 

The operation should be performed by 
the subperiosteal method ; the diseased tissue 
should be removed from the end of the tibia 
and the astragalus removed entire with the 
top of the os calcis, if diseased. 

There are many modifications of the lat- 
eral incisions which are in common use and 
other incisions radically differing ; but of all 
methods preference must be given, in the 
opinion of the writers, to that of Kocher, 
which has proved eminently satisfactory in 
their experience when a formal excision is to 
be done. 

The method is as follows: The foot is 
held at a right angle and a superficial incision 
is made along the outer border just below the 
external malleolus, reaching from the tendo Achillis to the extensor ten- 
dons. The peroneal tendons are dissected out, secured by sutures, 
and then cut by a second and deeper incision. The capsule along the 
anterior and posterior surfaces of the tibia is cut, the external lat- 
eral ligament divided, and the ankle-joint thus opened freely from 
the side. The foot is then dislocated inward as far as is desired, and 
the joint can be inspected to any extent. After the diseased parts 
have been removed, the foot is reduced to its proper position, the 
peroneal tendons are united, and the wound is closed. When the 




FIG. 167.— Treatment of Ankle- 
joint Disease by Thomas. 
Knee splint and plaster-of- 
Paris bandage on ankle. 



176 



ORTHOPEDIC SURGERY. 



foot is dislocated, an admirable view is obtained of the interior of 
the joint. 

The after-treatment of cases of ankle-joint excision is similar to the 
treatment of the others spoken of. Asepsis and immobilization in a 
correct position are the requirements ; and to this end infrequent dress- 
ings are very desirable. Plaster of Paris applied outside of a heavy 
dressing is very serviceable, as in knee-joint excision. An accurate and 
equally efficient splint is a wire posterior splint, which is made of a rod 
of "copper-washed iron wire" three-sixteenths of an inch in diameter, 
which is bent to fit the leg and padded except at the ankle, where it is 
covered with rubber tubing and can be rendered aseptic and incorpo- 
rated in the dressing there. The rest of the splint is padded. What- 




FlG. 168. — Radiograph of Ankle Ten Years after Cure following Removal of Astragalus for 
Disease. (Case of Dr. A. T. Cabot.) 

ever splint is used, one must be careful to see that the foot is at a right 
angle to the leg and in the same plane. For a long time after excision 
the joint should be protected from weight-bearing by the application of 
a Thomas splint or some such appliance. 



SHOULDER. 

Symptoms. — The general symptoms of ostitis of the shoulder differ 
in no way from those in the usual form of this disease in other more 
commonly affected joints, except that stiffness of the joint and malposi- 
tions due to muscular spasm are less noticeable on account of mobility 
of the scapula. The disease is insidious, extremely chronic, prone to 
suppuration, and decided impairment of the joint is likely to result. 

Pain is of a dull aching character, which is usually aggravated at 



TUBERCULOUS DISEASE OE THE SHOULDER. 177 

night, and is referred either to the joint itself or to the middle of the 
arm near the insertion of the deltoid. In many cases this symptom is 
absent or very slight. A slight increase of surface temperature may 
be detected. There will usually be found a tenderness, frequently 
localized over a small area, generally over the anterior surface of the 
joint, but sometimes on its posterior aspect. The patient instinctively 
holds the arm at rest, and attempts at passive motion provoke muscu- 
lar spasm, and if the attempt is persisted in, the humerus and scapula 
are seen to move together. Early in the disease a change in contour of 




FlG. 169.— Disease of Right Shoulder-joint Showing Atrophy and Change in Outline. 

the joint becomes apparent, which is due to enlargement of the head of 
the humerus as well as to muscular atrophy. When the swelling is due 
to effusion within the joint, the shoulder appears fuller and broader 
than normal, and this is seen best in looking down on the patient ; the 
natural depressions in front of and behind the joint become either oblit- 
erated or are the sites of prominences. 

Suppuration may occur. The subsequent course is slow, the result 
depending on the extent of the degenerative process, which may termi- 
nate soon after evacuation of the pus or continue to complete destruc- 
tion of the head of the humerus. 

The possible results are: recovery with a stiff joint (ankylosis), 
deformity and impaired muscular power, or entire destruction of the 
12 



i ;8 



ORTHOPEDIC SURGERY. 



head of the bone ; and in children later arrest of development of the 
humerus may result. 

Treatment.— In tuberculous ostitis at the shoulder-joint the indica- 
tions for treatment are practically the same as those presented in 
other joints. Distraction is not indicated in disease of the shoul- 
der, as, owing to the laxity of the joint, the weight of the dependent 
arm, if kept at rest, is sufficient to separate the humerus from the 
opposing bone surface of the scapular articulation. In very painful 
cases, should traction be required, it may be applied by weight and pul- 
ley traction during recumbency. 

On the whole, the results of the conservative treatment of tubercu- 
lous shoulder-joint disease are satisfactory except in the case of persons 




Fig. 



-Same Case as Fig. 169. 



Showing- limitation of abduction in attempt to raise both 
elbows. 



whose general condition is decidedly bad. The great freedom of move- 
ment of the scapula allows many arm motions to take place without any 
movement of the head of the humerus in the glenoid cavity, so that it 
is easy to secure almost complete rest to the affected joint. 

Excision of the joint should be performed if conservative treatment 
fails, being done earlier in adults than in children. 

The longitudinal anterior incision is in general the most useful for 
excision of the shoulder. The periosteum is divided with a bone knife, 
inserted along the inner border of the bicipital groove. The arm is 
rotated both outward and inward, and the periosteum and muscular 
attachments are removed as they appear. The head can be removed 
with the keyhole or the chain saw, removing as much of the bone as is 



TUBERCULOUS DISEASE OF THE ELBOW. 179 

diseased. The operation is performed subperiosteally and the head of 
the bone may be thrown out of the wound and thus sawed off. In after- 
treatment very good fixation can be obtained by bandaging the arm to 
the side, with a thick pad between the body and the inner side of the 
arm. Plaster-of-Paris dressing around the arm and chest affords the 




FIG. 171. — Radiograph of Tuberculous Disease of Left Shoulder. (Dr. C. F. Painter.) 

best fixation; and after the need of complete fixation is passed, a sling 
answers every purpose. 



ELBOW. 



Symptoms. — The disease may begin with pain, but this is not severe 
and often is entirely absent. Limitation of extension of the forearm is 
a constant and early symptom, motion in this direction being distinctly 
restricted when flexion, pronation, and supination are free. A slight 



180 ORTHOPEDIC SURGERY. 

increase of surface temperature is usually found, but its absence does 
not exclude the disease. Careful examination will reveal a slight 
amount of swelling even at this stage of the affection, shown by fulness 
and thickening on either side of the tendon of the triceps, and, looking 
at the elbow from behind, the joint appears broader than normal. As 
in other joints, wasting of muscles occurs rapidly. As the disease 
progresses the stiffness increases, motion in other directions is restricted 
and resisted by muscular spasm, and the joint is generally held at an 
obtuse angle. Starting pains maybe added to the other symptoms, 
and become the source of great discomfort. The whole joint becomes 
involved in the swelling, the enlargement assuming a fusiform shape. 

The swelling sometimes becomes very great. The skin may be- 
come riddled with sinuses, the tuberculous infection attacks the soft 
parts, and the whole elbow becomes a pulpy, granulating mass. This 
occurs in neglected cases of elbow disease and also as the result of 
relapses after excision of the joint. Tuberculosis of the head of the 
radius may exist, in which case limitation of rotation and local- swelling 
are predominant symptoms. 

The prognosis in tuberculous disease of the elbow is not favorable 
for re-establishment of motion, unless the affection is treated at a very 
early stage. The joint is so complicated that the disease involves a 
large and comparatively widespread surface of synovial membrane be- 
fore its presence is discovered. 

Treatment. — In tuberculous disease of the elbow fixation is de- 
manded. This is best furnished by plaster of Paris or moulded leather, 
which can be worn for some weeks and then be replaced with little dis- 
turbance of the joint. The frequent readjustment of splints is objec- 
tionable in a sensitive joint. In any event, a sling is to be carefully 
worn, which shall support the hand and wrist as well as the arm, and 
whatever apparatus is used it is essential to remember that the elbow 
should be flexed to a right angle, for if ankylosis occurs in any other 
position a useful arm is not obtained. 

When the joint is fixed by muscular spasm at an angle greater than 
a right angle, it will often be found possible to rectify this by the appli- 
cation of a fixation bandage to the arm in its malposition. This so 
quiets the muscular irritation that in two or three weeks it may easily 
be bent up a little and by the application of a succession of bandages it 
may often be brought into a right-angled position without the use of 
the least force. 

If the disease progresses, it is of little use to continue conservative 
treatment ; but one must proceed to arthrectomy, or, better yet, excis- 
ion, before amputation becomes the only measure holding out any 
prospect of relief. Forcible manipulation of an ankylosed arm is some- 
times useful after the disease has ceased to be active. 



TUBERCULOUS DISEASE OF THE ELBOW. 181 

Excision of the elbow is perhaps indicated earlier in the course of 
the disease than is the case in any other of the larger joints. After 
infancy is passed, operative interference is indicated whenever it is 
clear that under expectant treatment the disease is growing worse. 
Under these conditions the results are not, as a rule, altogether satis- 
factory, but if the disease is allowed to go on, the elbow-joint becomes 
so disorganized that amputation becomes necessary. 

Excision is also indicated for ankylosis in faulty position, as when 
the elbow is fixed in a position of much more than a right angle or very 
sharply flexed. The longitudinal incision is the most serviceable. The 
forearm is slightly flexed, and the incision, about three and one-half 
inches long, is made a little to the inner side of the median line over the 
triceps and ulna and is carried down to the bone throughout its entire 
length. The inner edge of the divided periosteum is raised from the 
ulna with the corresponding half of the tendon of the triceps, and the 
dissection is continued with the knife close to the bone, toward the 
internal condyle. Much care must be taken to preserve the connection 
between the periosteum, the muscular attachments, and the internal 
lateral ligaments. A similar dissection should then be made upon the 
outer side with the same precautions. The humerus is dislocated back- 
ward through the wound and sawed off wherever it may be neces- 
sary. In other cases it may be advisable to use the keyhole or chain 
saw, and so far as may be necessary the ulna is cleared and sawed 
through, the head of the radius being removed with the saw or bone 
forceps. 

In certain cases, in which sinuses exist, it may be better to adopt 
some informal method of operation, which will be suggested by the 
location of foci by the .i'-ray or by the direction and location of the 
sinuses or abscesses. 

The after-treatment is similar to that of other excisions: complete 
rest to the joint and fixation in a right-angled position. This at first 
can be best obtained by the use of a plaster-of -Paris splint applied out- 
side of a large antiseptic dressing. Later, in the course of the conva- 
lescence, bracketed tin or wooden splints may be of use ; or, if one de- 
sires, the original plaster-of-Paris splint may be bracketed with strips 
of iron. 

In excision for elbow disease, as a rule, ankylosis is aimed at as the 
best possible result, so that passive motion is not to be considered ; if, 
however, the operation is performed in adults for ankylosis or injury 
and the ligaments have been in a measure fairly preserved during the 
operation, it may be advisable to begin passive motion after a moderate 
degree of firmness in the tissues has been reached, as there is but little 
danger of a flail joint and it is reasonable to expect that a certain degree 
of motion at the joint may thus be obtained. 



1 82 ORTHOPEDIC SURGERY 



WRIST. 



Symptoms. — Tuberculous disease is characterized by swelling, heat, 
and stiffness. If the disease is advanced, deformity and swelling will 
be added to the other signs. The hand may be held flexed on the fore- 
arm at an angle of 120 to 130 , and this position is fairly constant. 
Swelling appears first in the depressions between the tendons. Later, 
measurement will show the joint to have increased in circumference, 
and there is a fulness of outline, especially on the dorsal surface, and 
in destructive disease the swelling extends up on the forearm and 
down on the hand. Suppuration is very liable to occur, and the course 
of the disease is usually long and slow. 

In the matter of diagnosis, it may be added that swelling is always 
present, and that with the wasting of the muscles, the heat, and the 
limitation of motion, it makes up the clinical picture of the disease. 

Treatment. — In tuberculous disease of the wrist-joint fixation is in- 
dicated, and it is most easily obtained by the application of anterior and 
posterior common wooden splints and carrying the arm in a sling. 
Plaster of Paris or a moulded leather splint forms a more permanent 
dressing and is equally comfortable. 

Compression is a valuable addition to the treatment, and Bier's con- 
gestive method, 1 as in the elbow and ankle, may be of use in addition 
to the usual mechanical measures. 

Excision of the joint is indicated in cases in children which do not 
make favorable progress under conservative treatment, in the cases of 
adults with severe disease, and is to be undertaken earlier in adults 
than in children. The best result is either ankylosis or limited motion, 
and, therefore, as much bone as possible should be saved. Other 
things being equal, a loose joint entails less power in the hands and 
fingers than a stiff one. 

The method of Lister is performed by a radial and dorsal incision. 
The radial incision commences at the middle of the dorsal aspect of the 
radius at the level of the styloid processes. It is directed toward the 
inner side of the metacarpophalangeal articulation of the thumb, and 
on reaching the radial border of the second metacarpal bone it is carried 
downward longitudinally for half the length of the bone. The soft 
parts are detached from the bones with the periosteal elevator or the 
blade of the knife, and the radial artery is thrust somewhat outward. 
The soft parts on the ulnar side are dissected up as far as is practicable, 
while the extensor tendons are relaxed by bending back the hand. 
The knife is then entered on the inner side of the arm for the ulnar 
incision two inches above the end of the ulna, and is carried downward 
in a straight line as far as the middle of the fifth metacarpal bone at its 
1 Freiberg: Amer. Jour, of Orth. Surgery, vol. ii., No. 1, p. 50. 



TUBERCULOUS SACRO-ILIAC DISEASE. 183 

palmar aspect. The tendon of the extensor carpi ulnaris is cat at its 
insertion into the fifth metacarpal and dissected up from its groove in 
the ulna, while the tendons of the extensors of the fingers with the 
radius are left undisturbed. The anterior surface of the ulna is cleared 
by cutting close to the bone. The anterior ligament of the wrist-joint 
is divided and the junction between the carpus and the metacarpus is 
cut, the former being extracted through the ulnar incision by bone for- 
ceps and the use of the knife. 

If the hand is everted, the articular heads of the radius and ulna 
will protrude at the ulnar incision, and as much as may be necessary is 
then removed. The metacarpal bones are also protruded and dealt 
with in the same way. The articular surface of the pisiform bone is 
cut off and the trapezium is dissected out. The operation may, how- 
ever, be performed by a long, single dorsal incision, a method identified 
with the name of Langenbeck, which should begin at the centre of the 
ulnar border of the metacarpal bone and the index finger, and be car- 
ried upward to the middle of the dorsal surface of the epiphysis of the 
radius, and dissected clown to the bone. The sheaths of the tendons 
are lifted with the periosteum and carried to the radial side of the long 
incision; the hand is flexed and the articular surface of the upper 
row of carpal bones is exposed. The ends of the radius and ulna 
may be denuded and thrust through the wound and sawed off in the 
usual way. Here, as in other excisions, informal methods of operating 
may be necessary on account of the situation of abscesses and sinuses. 

The operation is indicated when expectant treatment has failed, but 
the joint is so easily fixed and so accessible that mechanical treatment 
works at good advantage. Operation is attended with so much de- 
formity of the wrist and such doubtful results on account of the very 
extensive surface of the serous membrane that excision should not be 
lightly undertaken. The after-treatment is simple, because the hand 
can be kept so easily at rest upon a palmar splint ; but any form of 
splint may be applied which will afford permanent and efficient fixation. 
In children excision should be done only in severe cases, when conserv- 
ative treatment has failed. As in ankle-joint excision, the whole of 
every diseased carpal bone should be removed. 

SACRO-ILIAC DISEASE. 

By sacro-iliac disease is meant disease of the sacro-iliac synchon- 
drosis. This affection is also known as sacro-coxitis (Hueter), sacrar- 
throcace, and sacro-coxalgie. 

Disease of this joint is a rare condition. It is essentially a disease of 

young adult life, being slightly more common in men than in women.' 

It occurs occasionally in children. Chronic sacro-iliac disease is generally 

tuberculous. 

'Van Hook : Ann. of Surgery, 1888-89. 



1 84 



ORTHOPEDIC SURGERY. 



Etiology. — The etiology is also, in large part, similar to that of 
chronic disease of this type in other joints ; traumatism and the strain 
of parturition being assigned as the commonest causes. 1 

Symptoms. — In the early part of the disease such symptoms as a 
slight abdominal distress, difficulty in micturition or in evacuation of 
the bowels, fatigue, a feeling of indisposition, etc., are often present 
and as the disease progresses more pronounced signs appear. Pain 
is nearly always present, and may vary much in intensity. It is made 
worse by standing and is almost always relieved by lying down. It is 
also apt to be more severe at night, and is increased by pressure upon 
the trochanters or wings of the ilia. The pain varies in situation, and 




FlG. 172. — Sacro-iliac Disease (Non-tuberculous ). (Dr. J. E. Goldthwait.) 

maybe referred to the course of the sciatic nerve. Sensitiveness upon 
pressure over the joint is a common symptom, and this may be devel- 
oped over the anterior part of the joint by palpation through the rec- 
tum. Some swelling, or a boggy feeling, is usually present about the 
articulation, and if it goes on to abscess formation the fluctuating 
swelling may present at almost any point, either directly backward into 
the lumbar region, or it may become intrapelvic, in which case it may 
appear in the groin as a psoas abscess, or point in the ischio-rectal fossa, 
or at either of the sacro-sciatic notches. Limping is practically always 
present. 

The position of the body in walking or standing is fairly characteris- 
tic, the weight of the trunk being thrown upon the well foot, while the 
other leg hangs down; this exerts a slight extension by its weight. In 
'" Ref. Handbook of the Med. Sciences," vol. vi. , p. 240. 



TUBERCULOUS SACRO-ILIAC DISEASE. 185 

walking the gait is very cautious, all jar is avoided, and hence the toe is 
largely used instead of the flat of the foot on the diseased side. Atrophy 
of the muscles of the leg upon the affected side is usually present, and 
is seen, as in other chronic joint affections, quite early in the disease. 

Diagnosis. — Sacro-iliac disease has been mistaken for sciatica, but 
aside from the fact that the latter is usually found later in life, the 
pains are not relieved by the recumbent position. 

In lumbago the pain is more diffuse and higher up than in disease 
of the sacro-iliac articulation. 

Inflammation of the psoas muscle (psoitis) more usually simulates 
hip disease, but it may be mistaken for sacro-iliac disease. In this 
there is no tenderness over the joint and the pain which is present is 
increased by extension of the thigh, while flexion relieves it. 

Positive diagnosis of sacro-iliac disease from hip disease and Pott's 
disease in the lumbo-sacral region is at times difficult and often impos- 
sible, especially in the class of cases just referred to. In hip disease 
2II manipulation is resisted by muscular spasm, while in sacro-iliac dis- 
ease, with the iliac bones held firmly, all motions at the hip are possible 
without pain. Also in hip disease the pain is never increased by press- 
ure upon the wings of the ilia as is the case in sacro-iliac inflamma- 
tion. In Pott's disease we have a prominence of some of the spinous 
processes with rigidity of the spine when motion is attempted, and 
local tenderness is not present over the sacro-iliac articulation, nor does 
pressing together the ilia cause pain. 

Prognosis. — The prognosis in this disease is at best quite grave. 
Patients do recover, but it is one of the most chronic of joint affections, 
and usually goes on to abscess formation, with prolonged suppuration 
and death either from exhaustion, or renal complications, or secondary 
tuberculosis. 

Treatment. — The principles of treatment are the same as in all 
chronic joint affections. In the acute stage the patient should be kept 
upon the back in bed, with weight-and-pulley extension to the leg to 
steady the limb, and as the acute symptoms abate he may be allowed 
to go about on crutches, with a high sole upon the well foot, the weight 
of the other leg serving as extension. While moving about, a certain 
amount of comfort may be derived from a swathe, of either leather, or 
adhesive plaster, or plaster of Paris, about the pelvis, which serves in 
part to fix the joint. 

When an abscess has formed it should at once be laid open, any 
diseased bone removed, and treated like any cold abscess. When the 
abscess is intrapelvic it may be quite difficult to reach. Excision of the 
sacro-iliac synchondrosis may be done in severe cases. 

In all of these cases tonics and constitutional treatment are not to 
be neglected. 



CHAPTER VI. 

INFECTIOUS OSTEOMYELITIS — INFECTIOUS 
SYNOVITIS AND ARTHRITIS. 

Infectious osteomyelitis (Etiology. — Pathology.— Symptoms. — Diagnosis. — Dif- 
ferential diagnosis. — Prognosis. — Treatment). — Spine. — Typhoid spine. — Hip. 
— Acute arthritis of infants. — Infectious synovitis and arthritis (Etiology. — Pa- 
thology. — Treatment). — Gonorrheal arthritis (Varieties. — Pathology.— Etiol- 
ogy. — Treatment). 

INFECTIOUS OSTEOMYELITIS. 

This process, 1 primarily attacking the bones and at times seconda- 
rily affecting the joints, is the result of an infection by some pyogenic 
bacterium. It attacks preferably the diaphysis of the long bones, gen- 
erally near the epiphysis, and as a rule one bone only is attacked, but 
in exceptional cases several may be involved. It occurs usually in bone 
which has not become fully developed. If it is confined to the shaft of 
the bone the joints are not involved, but when it is located near the 
ends of the bone the joints are frequently invaded. 

Etiology. — The organism most frequently found is the staphylococ- 
cus pyogenes aureus, 2 although the aureus and the citreus are some- 
times present. The lesions produced by this organism are, as a rule, 
the most typical and extensive. The streptococcus pyogenes 3 is less 
commonly seen and the lesions caused by it are more liable to attack 
the periosteum and the superficial part of the bone, to cause separation 
of the epiphysis, and to involve the joints. The pneumococcus at times 
is the cause of a process indistinguishable from that caused by the 
streptococcus. 4 The typhoid 5 bacteria may cause suppuration in bone, 
usually in small and superficial areas, unless a secondary infection with 
some other organism is present. Secondary infections with other or- 
ganisms have been reported. The femur, the tibia, and the humerus 
are the bones most commonly attacked. 

Infectious osteomyelitis is not a specific disease, but the result of 
infection by one of a variety of pathogenic organisms, and it has. been 

1 E. H. Nichols: Journal Am. Med. Assn., 1904. 

- Lannelongue : Revue de Chir. , 1895. — Lannelongue and Achard : Arch, de 
Med. exp. et d'Anat. path., 1892. 

"Lexer: Volkmann's kl. Vort, N. F., 173, p. 659. 

4 Fischer and Levy: Deut. Zeit. f. Chir., 1893. 

5 Keen: " Surg. Compl. of Typhoid Fever," 1898. 

186 



INFECTIOUS OSTEOMYELITIS. 



187 



produced experimentally. 1 As a rule it occurs at or shortly after the 
age of puberty, although young children are often infected and adults 
are not exempt; it occurs more frequently in boys than in girls. The 
affection may arise in the bone without evidence of disease in other tis- 
sues, the organism finding its entrance through an unknown or appar- 
ently insignificant source of infection. The disease appears frequently 
after trauma, extreme fatigue, and exposure to cold and wet ; it also 
occurs secondarily to a previous disease, such as typhoid fever, scarlet 
fever, or similar infectious disease. At other times it is secondary to a 
local infection in some other part of the body, such as furuncle, car- 
buncle, erysipelas, septicaemia, 



pneumonia, 



or em- 



pleurisy 
pyema. 

Pathology. — The bone mar- 
row is the part primarily attacked. 
The trabecular and cortex are at 
first but slightly involved, though 
later extensive destruction may 
take place. The process may 
spread extensively in the marrow 
before it pierces the cortex, where 
it extends and causes suppuration 
between the bone and periosteum 
and later in the soft tissues, de- 
veloping an abscess which may 
evacuate, with the establishment 
of a sinus leading to necrosed 
bone. If the periosteum has 
been extensively separated from 
the cortex, extensive necrosis 
of the shaft follows, surrounded 
by a formation of dense cicatri- 
cial bone. As a rule the proc- 
ess does not extend to the epiphysis, but there maybe a complete 
destruction of the epiphyseal line and a separation of the epiphysis. 
When ossification has obliterated the epiphyseal line the process 
may extend to the joint, being checked temporarily by the carti- 
lage, but subsequently invading the joint, with joint destruction. De- 
formities develop as a result, but even when joint destruction has not 
taken place deformity may result from the destructive changes in the 
soft parts adjacent to the joint, which cause impairment of motion, 
ankylosis, and displacement of joint surfaces. When contiguous por- 

1 Lexer: Deutsch. med. Woch., xvi., 1894.— Ackerman : Arch, de Med. exp. 
et d'Anat. path., 1S95. 




FlG. 173. — Acute Infectious Osteomyelitis of 
Tibia Involving Knee-joint. 



88 



ORTHOPEDIC SURGERY 



tions of bone are destroyed by necrosis extensive deformity may 
result. 

Symptoms. — The affection begins suddenly with severe general dis- 
turbances, accompanied by pain in the affected bone, often in the vicin- 
ity of a joint which is. held rigid on account of the pain. The attack 
may be of great severity and the symptoms may resemble those of 
typhoid, thus masking the local symptoms. At other times the attack 
is much less severe, the general symptoms being those of a moderate 
general infection. As a rule the local symptoms are of moderate sever- 
ity, and in addition to the pain there are present swelling and tender- 
ness of the parts about the affected bone, elevation of temperature of 
a greater or less degree, increase of pulse, and symptoms of sepsis in a 
degree varying with the severity of the case. Increased leucocytosis is 




FIG. 174.— Acute Osteomyelitis of the Knee-joint. 

present and delirium in the severer cases. This stage of onset, espe- 
cially when of moderate severity, may be overlooked by the attendants 
of the patient, whose attention is centred on the severity of the local 
symptoms. If the disease is left unrelieved the condition becomes rap- 
idly worse, in the severer cases markedly septic symptoms appearing. 

Diagnosis. — The diagnostic signs of the condition are rapid onset, 
marked rise of temperature, mild or severe symptoms of sepsis, in- 
creased leucocytosis, and signs of a severe inflammatory process over 
the end of one of the long bones. In the early stage the ,r-ray does 
not afford a means of diagnosis. 

Differential Diagnosis. — Typhoid Fever. — The initial stage of a se- 
vere type of the affection may be confounded with typhoid fever. In 
the latter, however, the bone symptoms when they occur are late and 
of less severity, and on careful examination cases of osteomyelitis will 
be found to lack the characteristic diagnostic signs of typhoid, the 
resemblance being only superficial. 

Rheumatism. — The less severe grades of the affection are frequently 



INFECTIOUS OSTEOMYELITIS. 189 

diagnosticated as rheumatism. The rapid development of osteomyeli- 
tis, the septic character of the symptoms, the severe localized pain, and 
the development of a process evidently suppurative will in most cases 
suffice to differentiate the two. 

Tuberculous Disease. — In the mild cases the resemblance to an 
acute degree of tuberculosis of the joint is not infrequent. The process 
is, however, more acute and severe, the temperature is higher, leuco- 
cytosis is more constantly present, and although in certain cases the 
diagnosis is one of difficulty, it can ordinarily be made by a careful 
examination on the lines indicated in speaking of the two affections. 

Prognosis. — In the severer types of this affection the condition is 
grave and the danger of septicaemia is considerable. The prognosis 
depends in a measure on the stage of the infection at. which operative 
relief is afforded. In the less severe cases a stage of extreme pain per- 
sisting for some weeks is followed by abscess development with necrosis 
and the establishment of sinuses. When the affection is near the joint 
in young children the liability to dislocation and separation of the epiph- 
ysis is to be borne in mind. Young infants, who are frequently af- 
fected, in the majority of cases make good recoveries with early opera- 
tive treatment. The motion of the joint is not necessarily lost where 
early operation is undertaken, but ankylosis is commonly an outcome 
of the severe grades of the condition. 

Treatment. — The treatment varies with the stage of the disease. 
In the acute stage if the symptoms are at all severe the indication is to 
cut down upon the diseased area, to wash out the diseased tissue, or to 
establish drainage. As the focus is in the marrow, the cortex of the 
bone is to be trephined until the marrow is reached and drainage estab- 
lished. Where exact localization is not possible the bone can be tre- 
phined in the diaphysis near the epiphyseal line. The marrow should 
not be curetted, as it is desirable to save the endosteum. If the symp- 
toms are slight it may be safe to delay active interference, but judgment 
should favor incision and drainage in all doubtful cases. 

In the subacute stage it is desirable to remove the necrotic area to 
establish the regeneration which takes place through the periosteum. 
The periosteum should be separated from the bone, and in cases with 
extensive disease the diseased shaft removed and the inner edges of the 
periosteum placed in apposition, to favor the formation of new bone. 
The removal of this necrotic portion should not be attempted until the 
acute stage has passed, usually about two months after the first onset 
of the disease. 

In the chronic stage the treatment involves the consideration of not 
only the removal of the sequestrum, but the filling of the remaining 
cavity with normal bone. As the cavity is surrounded by thick, hard 
bone with little vascularity, it does not readily develop new, healthy 



190 ORTHOPEDIC SURGERY. 

bone growth. Sinuses persist indefinitely, the cavity being filled with 
granulation tissue (Nichols). 1 

The removal of the shaft as well as the sequestrum and stitching 
the surfaces of the uppermost sides together is indicated. In the 
tibia, where the fibula acts as a splint, this can be done, but where no 
splint of bone is present a part of the involucrum must be left. . The 
periosteum should be applied closely to it, regeneration of bone taking 
place from the inner surface of the periosteum and from healthy endos- 
teum. 

When the joint is involved the treatment is conducted on the same 
principles. In the acute stage drainage should be established as soon 
as possible by free incisions. In the subacute stage where no sinus 
has been established the joint will need fixation and protection to check 
the progress of the disease and to prevent deformity. The treatment 
under the circumstances resembles that given in tuberculous joint 
affections. In the chronic stage with sinuses and sequestra, the treat- 
ment consists of the thorough drainage of bone with the free removal 
of the hardened bone. If the cavity necessary for complete drainage is 
a large one, it can be left to fill in with granulation or can be covered 
in with a periosteal flap. 

The treatment of the deformities following infectious osteomyelitis 
is similar to that of the deformities following tuberculous ostitis. Forci- 
ble rectification of contracted joints, with or without osteotomy or in- 
cision, may be needed. Such operative interference should not be 
undertaken until the stage of cicatrization has been established. 

Spine. 

Acute Osteomyelitis. — The spine is not commonly attacked by this 
disease. In 1903 about fifty well-authenticated cases had been re- 
ported. 2 

The most common age of onset is from six to fifteen, but younger 
children and adults are not exempt. The process may attack either the 
vertebral arches or the bodies, and is of the same general character as 
osteomyelitis elsewhere, modified by the peculiar structure of the ver- 
tebral column. It occurs under the same conditions as those of the 
general process. Secondary centres of suppuration are likely to occur 
elsewhere in the body. The lumbar region is most frequently affected, 
but no part of the spine is exempt. 3 

The symptoms are stiffness, tenderness and pain, high fever, and 
much constitutional disturbance. Abscess occurs in practically all 

'Journal of the Amer. Med. Assn., February 13th, 1904. 
2 Grisel: Revue d'Orthopedie, September, 1903. 

3 Gross: " Osteomyelitis of the Lateral Parts of the Sacrum." Deutsch. Zeit. 
f. Chir. , lxviii , 95. 



INFECTIOUS OSTEOMYELITIS. 191 

cases and the tissues around the abscess become cedematous. Al- 
though posterior abscesses are accessible, anterior abscesses are almost 
impossible to locate. Paralysis occurs in about one-third of the cases. 

Deformity of the spine is not of frequent occurrence, because, al- 
though the process is rapidly destructive, the new formation of bone is 
rapid and the severity of the disease necessitates recumbency. 

The mortality has been said to be as high as sixty per cent, but this 
cannot be accepted as accurate, as the less severe forms of the affection 
may often have been overlooked. 

Direct incision to the bone furnishing drainage is indicated as soon 
as is possible. During convalescence the spine should be supported as 
in Pott's disease. 

Typhoid Spine. — In the later stages of typhoid fever an acute, pain- 
ful condition of the spine, presenting symptoms similar to those of 
very acute Pott's disease, occasionally is seen. Although pathological 
proof is wanting, it seems likely that the affection is a localized and 
often superficial osteomyelitis of the vertebral column. The nervous 
symptoms are most marked, and disturbances of sensation and pares- 
thesia are frequently present. Deformity is not the rule and when it 
occurs is small in extent. The prognosis for ultimate recovery is good 
and the treatment does not differ from that of acute Pott's disease. 1 

Hip. 

Acute Osteomyelitis. — This location of osteomyelitis is compara- 
tively frequent. In 758 cases of disease of the hip at the Gottingen 
Clinic, 2 there were no cases of acute infection and 568 cases of tubercu- 
losis. This proportion is practically the same as that found by Brims. 3 

The process may be acute and rapidly destructive or slower and less 
acute. 

In infants it is rather a violent process, accompanied by high fever 
and much swelling about the hip. Pain and constitutional disturbance 
are marked. Flexion of the limb and muscular spasm are pronounced 
and abscess occurs in most if not all cases. The process may cause 
separation of the epiphysis of the femur, destruction of the head of the 

1 Konitzer : Miinchener medicinische Wochenschrift, August 29th, 1899(46 
Jahrg., No. 35). Philadelphia Medical Journal, February 10th. 1900. — Frederick 
T. Lord: "Analysis of Twenty-six Cases of Typhoid Spine" (with literature). 
Boston Medical and Surgical Journal, June 26th, 1902.— R. W. Lovett and C. F. 
Withington : Boston Medical and Surgical Journal, March 29th, 1900. — E. G. Cut- 
ler: Boston Medical and Surgical Journal, June 26th, 1902, p. 687. — E. Fraenkel : 
" Ueber Erkrankungen des rothen Knochenmarks, besonders der Wirbel, bei ab- 
dom. Typhus," Hamburg. Mittheilungen a. d. Grenzgebieten. Jena. — Journal of 
the American Medical Association. April 25th, 1903. 

-Konig: "Die spec. Tub. der Knochen u. Gelenke," xi., Berlin, 1902. 

3 Bruns and Honsell: Beitr. z. klin. Chir. , xxiv. , 1 ; xxxix. , 3. 



192 ORTHOPEDIC SURGERY. 

femur, or dislocation of the hip by destruction of the capsule without 
destruction of the head. In the latter cases the disease of the bone is 
probably situated a little farther from the articular surface. In each 
of these conditions the hip is found completely dislocated with perhaps 
grating in the joint. In such cases later in life a condition resembling 
congenital dislocation of the hip is found where the stump of the femur 
is loosely connected with the acetabulum. This condition is spoken of 
as floating psendoartJirosis or pseudoarthrose flottante} Extensive 
osteomyelitis of the femur may remain after the hip symptoms have 
been relieved by operation. 

In older children the process is less violent and bears more resem- 
blance to tuberculosis of the hip in its clinical aspect. The symptoms 
are, however, more severe. It is attended by high fever, leucocytosis, 
and perhaps delirium ; there is much swelling, and the joint symptoms 
are of a very marked character. Shortening may occur rapidly and 
abscess is practically universal. In some cases the affection is less 
acute, and in these the diagnosis from tuberculosis often cannot be 
made until the abscess is opened and a culture made from its contents. 

Coxa vara may result from the faulty union of a loosened epiphysis 
or from a spontaneous fracture of the neck. 

The treatment of the disease does not differ from that of osteomye- 
litis in other joints. The hip-joint, however, may require traction or 
protection after operation. 

In other joints the affection presents no peculiar characteristics. 

Acute Arthritis of Infants. 

This condition, recognized clinically since its description by Thomas 
Smith in 1874, 2 is now identified as a variety of osteomyelitis affecting 
the joints in young infants, the exact pathological history of which is 
not known. The onset is severe and is characterized by elevation of 
temperature, marked general disturbance, and local swelling about the 
joint, which is quickly followed by suppuration, the formation of an 
abscess, and disorganization of the joint, with extensive destruction of 
tissue unless the process is arrested by early operation. Spontaneous 
evacuation of the abscess may occur. In the severer cases separation 
of the epiphysis, dislocation, or the formation of a flail joint may result. 
Death may occur from septicaemia, and the prognosis is not so good in 
cases in which more than one joint is affected. The prognosis depends 
more upon the performance of an early effective operation than on 
anything else. The death rate has been variously given, 3 but recovery 

1 Ducroquet et Besancon : Presse Med., No. 15. 1903. 
'-' St. Bartholomew's Hosp. Reports, vol. x., 1874. 

:; Gonser: Jahrb. f. Kinderh., July, 1902. — Hoffmann: Med. Bull. Wash. 
Univ., September, 1902 — Whitman: " Orth. Surg.," 2d ed., p. 271. 



INFECTIOUS SYNOVITIS AND ARTHRITIS. 193 

frequently occurs in cases in which early operation is possible. Treat- 
ment should consist in free incision and flushing out of the affected 
joint with free drainage. The operation should be followed by fixation 
until the wound is closed. The hip and knee are the joints commonly 
affected. 

INFECTIOUS SYNOVITIS AND ARTHRITIS. 

An inflammation of the joints may occur in connection with acute 
infectious diseases, which may be acute or chronic, serous or purulent. 

Etiology. — The lesions which occur are to be attributed to the pres- 
ence in the joints of micro-organisms or their products, and the organ- 
isms found in the joints are either the staphylococcus, the streptococ- 
cus, or the organism peculiar to the primary disease. The affection 
may involve one or several joints, and attacks children more commonly 
than adults. 

The infectious diseases in which joint complications occur ] are as 
follows: Cerebro-spinal meningitis, diphtheria, dysentery, erysipelas, 
epidemic parotitis, glanders, gonorrhoea, epidemic influenza, measles, 
pneumonia, pertussis, puerperal fever, pyaemia, septicaemia, scarlet 
fever, smallpox, tonsillitis, typhus fever, typhoid fever, after the use of 
sounds and catheters, and possibly in malaria. An affection of the 
joints of a similar character is seen at times where no antecedent infec- 
tious disease can be identified. 

In the same connection must be mentioned pyogenic infection of 
the joints from wounds and similar outside sources. 

In consequence of some of the above-mentioned infections there 
arises a joint affection of another type, not to be distinguished clinically 
from arthritis deformans.' 2 It will be considered in that connection. 

Pathology. — The affection is most often manifested by an acute 
serous, sero-purulent, or purulent inflammation of the joint, accompa- 
nied at times by a deposit of fibrin. The process is generally most 
evident in the synovial membrane, and, although bony involvement by 
extension may occur, it is not the rule. In purulent cases there is sup- 
puration of the synovial membrane with loss of epithelium, and in se- 
vere cases the formation of granulation tissue, fibrous degeneration, or 
even necrosis of the cartilage and damage to the ends of the bones and 
destruction of the ligaments. Spontaneous luxations may occur and 
ankylosis must result in the severest cases. In a great part of the cases, 
however, the local process runs its course without great damage, and 
even in suppurative cases early incision is usually resorted to before the 
process has accomplished extensive destruction. Less commonly these 
processes are chronic or subacute. 

1 For literature see second edition of this book, p. 194. 

2 J. E. Goldthwaite : Boston Med. and Surg. Journ., 1904. 
13 



194 ORTHOPEDIC SURGERY. 

Symptoms. — The symptoms vary, according to the grade and char- 
acter of the infection, from those of a simple synovitis to those of a 
severe suppurative process. 

Treatment. — In the milder cases the treatment is that of synovitis. 
In suppurative cases the joint should be freely opened, washed out, 
and drained as soon as the existence of suppuration is recognized. 

The only modification of the usual free incisions in general use is 
to be found at the knee-joint, in which, in severe cases, it may be found 
advisable to make an extensive U-shaped incision, cut the patella ten- 
don across, and fix the knee in a flexed position after the method of 
Mayo. In this way the joint is thoroughly drained. The patella ten- 
don is sutured when repair is established. 

GONORRHCEA. 

Gonorrhceal synovitis or arthritis, and gonorrhceal rheumatism are 
the names most commonly applied to an inflammation of the joints 
occurring in the later stages of gonorrhoea. 

This inflammation is acute or chronic, and is most often polyarticu- 
lar. 1 

Varieties. — The commonest inflammations are as follows : 

Arthralgia, without definite lesions or associated with slight periar- 
ticular lesions or bursitis. 

Acute synovitis, monarticular or polyarticular, resembling acute 
rheumatism, with considerable periarticular swelling. 

Periarticular inflammation with joint effusion absent or subordinate. 

Tenosynovitis occurring about the joints, but not necessarily in- 
volving them. 

Chronic synovitis, serous or purulent, occurring as a sequel to the 
acute forms or begins as a chronic affection. This, if prolonged, may 
lead to changes in the joint, such as laxity of ligaments, etc. 

Pathology. — The effusion, if serous, is generally thick and may con- 
tain clots of fibrin. It may be sero-purulent or purulent. The effusion 
may be colored by blood. In the severer cases the joint changes may 
not differ from those described in the arthritis due to pyaemic processes. 2 
The striking feature is the amount of granulation tissue formed. Such 
a process shows little tendency to involve bone or cartilage, being essen- 
tially synovial. Ankylosis is to be feared. The inflammation shows 
the same tendency toward fibrous hyperplasia in the joints that it does 
in the urethra, which, of course, tends to impair joint motion. 

Etiology. — The affection has been demonstrated to be due to the 
gonococcus. The gonococci are found in the joint effusion in many 
cases. They are more likely to be found in acute than in chronic 

1 Trans. Assn. Am. Physicians, vol. x., p. 150. 
- Wien. klin. Woch.. January 15th and 23d, 1903. 



INFECTIOUS SYNOVITIS AND ARTHRITIS. 195 

cases. The gonococci may be present in the pus cells of the granula- 
tion tissue, or if in the exudate, in phagocytes or in epithelial cells free 
or in clumps. They may, however, not be found in the effusion or in 
sections of the synovial membrane. A mixed infection with pyogenic 
organisms may be found, or, rarely, pyogenic organisms alone may be 
found in the joint fluid. Suppuration of the joint is not necessarily 
associated with mixed infection. 

Men are much more frequently affected than women. The compli- 
cation rarely, if ever, occurs before the third week of the disease, and 
occurs in about two per cent of all cases. Involvement of the joints 
may occur after the passage of a sound into the urethra, in the vulvo- 
vaginitis of little girls, and in the gonorrhceal ophthalmia of babies. 1 

The joints affected were as follows in the order of their frequency 
in Northrup's series: Knee, 91; ankle, 57; small joints of foot, 40; 
wrist, 27; heel and toes, 21; elbow, 18; hip, 16; shoulder, 16; small 
joints of hand, 11 ; sterno-clavicular joint, 3 ; temporo-maxillary joint, 2. 

The prognosis can hardly be formulated. The affection is always 
serious and generally slow in progress and resistant to medication. In 
the acute stages suppuration is to be feared, and impairment of motion, 
perhaps ankylosis, is not unlikely to result. Simple cases perhaps oft- 
enest recover after a long time with practically normal motion. 

The duration in Northrup's cases was : 

Cases. 

One to six weeks 64 

Six weeks to two months 54 

Two months or more 77 

Indefinite 57 

Treatment.— In the acute stage the affection should be treated like 
other forms of synovitis and the fluid withdrawn from time to time for 
examination. Suppuration demands incision and drainage. Convales- 
cent cases should be treated as if convalescent from ordinary synovitis, 
only with greater care. 

Obstinate and persistent chronic synovitis, if in the hip, should be 
treated by protection, and perhaps traction by apparatus. Fixation by 
plaster bandages is to be used if the joint is painful. More accessible 
joints are best treated by free incision and flushing out with hot sterile 
water or hot weak corrosive solution in obstinate cases. Drainage for 
afew days should be kept up by strips of gauze, and the joint should be 
washed out daily in severe cases. In such cases incision and drainage 
are often followed by cessation of pain and marked improvement. 

If operation is not practicable the ordinary measures in use for the 
treatment of chronic synovitis are to be used. 

1 Editorial. Am. Medicine, April 25th, 1903. — R. B. Kimball: " Gonorrhoea in 
Infants." Med. Record. November 14th. 1903. 



CHAPTER VII. 
ARTHRITIS DEFORMANS. 

Definition. — Pathology. — Etiology. — Symptoms. — Varieties. —Frequency. — Diag- 
nosis.— Prognosis. — Treatment. 

Spine. — Spondylitis Deformans. — Pathology and etiology. — Symptoms. — Diagno- 
sis. — Prognosis. — Treatment. 

Hip. — Etiology and Pathology. — Symptoms. — Diagnosis. — Treatment. 

Knee. — Symptoms. — Prognosis. — Treatment. 

Shoulder. — Wrist. — Temporo-maxillary joint. 

The affection is known by a multiplicity of names, of which the fol- 
lowing are the principal ones : Arthritis deformans, rheumatic gout, 
chronic rheumatic arthritis, arthrite seche, osteoarthritis, nodosity of 
the joints, rheumatoid arthritis, nodular rheumatism, dry arthritis, pro- 
liferating arthritis, malum senile, and chronic articular rheumatism. 

The name arthritis deformans, proposed by Virchow, is used here, 
as it is descriptive and involves no etiological theory or pathological 
basis. 

Definition. — Arthritis deformans is a chronic, non-suppurative affec- 
tion, which attacks the joints, crippling and deforming them. Although 
the affection is a chronic one, it is subject to acute exacerbation. The 
disease is common, and affects not only man, but many other animals, 
such as horses, cattle, dogs and other carnivora, and even birds. The 
affection varies in its manifestations, as may be inferred from the vari- 
ous names which have been assigned to it. Some confusion has arisen 
in the minds of practitioners from the terminology, which has associ- 
ated the affection with rheumatism, the disease having been called 
chronic rheumatism, chronic rheumatoid arthritis, etc. The affection 
is one of a distinct type with variations, and is characterized by stiff- 
ness, some pain, and discomfort of the affected joint, with gradual 
progress of the disease and subsequent distortion and malformation of 
the joints. 

Pathology. —The pathology of this affection has been the subject of 
much discussion and is not yet understood. Some writers have claimed 
that it is of infectious origin, 1 others that it is dependent upon changes 

^chuller: Berl. klin. Woch., 1S93. 865. — Dor: Comptes rend. Soc. de Biol., 
1893, 899. — Bloxall : Lancet, 1896, i., 1120.— Bannatyne, Wohlmann, and Bloxall : 
Lancet, April 25th, 1896. — Teissier: "Du Rhum. goutteux." Lyon Med., 1897, 
169. — Charrin : "La rhum. chron. de Pinfection." Prog. med.. 1894, No. 43. — 
Pribram : " Chr. Gelenkrheum. und Osteoarthritis Deformans," Wien, 1902, p. 95. 

196 



ARTHRITIS DEFORMANS. 



197 



in the central nervous system, and others that it is due to the presence 
of some toxin as yet unknown. In -the opinion of several observers the 
disease can be divided into two or more distinct affections. Further 
investigation is needed to determine these questions. The pathological 
changes are, however, characteristic and fairly well defined. They may 
be said to consist of fibrous degeneration of the tissue of the joints, 
with resulting changes in the development of scar tissues, and in the 
more advanced cases ' in the transformation of degenerative fibrous tis- 




FlG. 175.— Arthritis Deformans of Knee-joint. 

sues into abnormal bony growths. The process may at any stage be- 
come arrested and stationary. The affection begins in the synovial 
membrane, the cartilage being attacked either at the same time or but 
little later. The synovial membrane and capsule are congested, swol- 
len, thickened, and in parts relaxed. If the joint is opened, in addition 
to the congestion of the synovial membrane one finds thickening of the 
villi and folds of the membrane, which may be extensive, so that an 
arthritis villosa may be said to exist. In some instances these enlarge- 
ments may take on cartilaginous formation and even ossification, and, 



198 



ORTHOPEDIC SURGERY. 



if they become freed from their attachments, they may become loose 
bodies in the joint. In other cases the enlargements undergo a fatty 
degeneration, so that they have been regarded as fatty tumors. The 
term lipoma arborescens is applied to this condition. 1 

The cartilage of the joints becomes affected in spots and shows 




w-?m<^- 



Fig. 176.— Vertical Sec- 
tion through Part of the 
Bodies of Sacral Ver- 
tebras from a Case of 
Spond yl itisDeformans. 
Drawing shows the 
new formation of dense 
bone along the anterior 
surface which is espe- 
cially marked at the 
intervertebral discs. 
(By the courtesy of the 
Department of Surgi- 
cal Pathology of the 
Harvard Medical 
School.) 





1 


f 


m 


\t- 


i 


f 





Fig. 



[77.— Arthritis Deformans of Hip. (Warren 
Museum.) 



fibrillary thinning, degeneration, and vascularization. Pannus may de- 
velop, which becomes united with the growth from the synovial mem- 
brane. In some cases in which the cartilage is covered by pannus 
there follows the formation of cicatricial tissue and fibrous or bony an- 
kylosis, with possible subluxation and distortion of the joints. The 
1 Painter and Erving : Amer. Jour, of Orth. Sur. , vol. i.. No. 2, p. 109. 



ARTHRITIS DEFORMANS. 



199 



cartilage may be entirely absorbed and bare surfaces of bone left, 
which become thickened. In other places there may be areas of carti- 
laginous thickening or hypertrophy, but where interarticular pressure 
occurs areas of absorption of cartilage are likely to be found. In cer- 
tain cases when the pressure is more gradual histological changes may 
take place in the cartilage in a different way. The osteoid elements in 
these cases apparently invade the cartilage, with the development of 
bone in irregular directions, the regions of the exposed bone being 
filled with osteoid elements, so that a layer of hard, cicatricial bone is 
developed. 

In the marrow various changes may occur. Fatty and mucoid de- 




FlG. 178. — Bones of Hand Badly Deformed by Arthritis Deformans. (Warren Museum.) 



generation may follow the destruction of the cartilage, giving the bone 
greater translucency to ,t'-ray illumination, or osteoid cells may be de- 
veloped and abnormal bone be found in regions where it does not be- 
long. Irregular formation of bone may also take place in the perios- 
teum, the fibrous attachment of the capsule, the ligaments, and the 
insertion of the periarticular muscles; this process is preceded by 
fibrous thickening. The absorption of the parts of the bone spoken of, 
with the changes induced by the irregular pressure, the abnormal 
growth of exostoses, and the consequent changes of shape complete the 
distortion. The distortion of the joint is also the result not only of the 
changes in the shape of the bones, but also in their relation to each 



200 



ORTHOPEDIC SURGERY. 



other. It is due partly to relaxation of the capsule in places, with con- 
traction in other places, and to pull of the muscles from the muscular 
spasm reflex to joint irritation. The immobility of the joint, its altered 
function and the consequent development of new bone, and the inflam- 
matory or irritative changes in the periarticular tissues and in the peri- 
osteum, all contribute to the distortion of the joint. , As a rule, the cap- 
sule and capsular ligaments are the parts chiefly involved, the wearing 
away of the cartilage occurring only at points of interarticular pressure 
A in a joint restricted in motion. In 

other cases the changes in the 
shape of the bones by the develop- 



« 







ta 



ment of marginal exostoses are 
considerable. In other cases the 
synovial changes predominate, with 
the development of villi and pos- 
sible pannus and cartilaginous ab- 
sorption. In lighter cases the 
changes in the cartilage are limited 
to a diminution in its normal glis- 
tening appearance. It must be 
remembered that tuberculous de- 
generation of chronically enlarged 
synovial villi may occur, but it is 
to be regarded as a pathological 
process distinct from arthritis de- 
formans. 

The muscles controlling the 
joint become changed and undergo 
atrophy and fibrous degeneration, 
and certain muscles may become 
contracted, while others are over- 
stretched. The periosteal muscle 
attachments are thickened and are 
likely to become the seat of the de- 
posit of bone. The periarticular subcutaneous tissue and the fascia in the 
vicinity of the joint are likely to become involved in the process. In 
this case they are found to be (Edematous, and swelling followed by hy- 
perplasia and permanent thickening occurs. The synovial fluid in some 
instances, especially in the more acute stages, is increased in amount 
and becomes slightly turbid. Acute enlargement of the lymphatic 
nodes and the spleen is not often seen in the arthritis deformans of 
adults. Still ' has, however, described such enlargement in a separate 
form of the disease seen in children. Such changes diminish or disap- 
1 Medico-Chir. Trans., 1897. 




Fig 



[ 79 . 



Spondylitis Deformans Showing 
Deposits of Bone at the Sides of the Verte- 
bras. (Warren Museum.) 



ARTHRITIS DEFORMANS. 



201 



pear as the patients become older. The blood is normal in most cases, 
as to the percentage of haemoglobin, the leucocyte count, and the 
differential count. The urine shows no characteristic changes. Gold- 
thwait has found an increased elimination of calcium salts. 

Complications are not uncommon in advanced cases, from enlarge- 
ment of the heart, chronic nephritis, and the various manifestations of 
arteriosclerosis. 

Etiology. — The etiology of the affection is not yet definitely deter- 
mined. In certain cases injury is ascribed as the exciting cause, but, 




Fig. 180.— Arthritis Deformans of Hip-joint Showing Shortening of Neck of Femur. Broad- 
ening of head and broadening and loss of depth in acetabulum. (Warren Museum. ) 



as in a majority of cases the disease develops without obvious traumatic 
origin, the connection between the injury and the pathological process 
is not evident. Some disturbance of metabolism is apparently con- 
nected with many of the cases. 

Frequency and Age. — The affection is common in old age, as may be 
seen from the following figures, taken from the Long Island Pauper 
Institution in Boston. Out of 66 men between sixty and eighty years 
of age 12 showed marked manifestations of arthritis deformans to a 
degree which interfered with locomotion and activity. In none were 
Heberden's nodes observed. In the women's department of the alms- 
house, of 96 patients only 5 showed affection of the larger joints, while 



202 ORTHOPEDIC SURGERY. 

12 had developed Heberden's nodes. Out of 26 cases in men, the dis- 
ease made its first appearance in 7 between the ages of fifty and fifty- 
nine, and in 46 women in 10 between forty and forty-nine. 

In McCrae's ' series of cases the age of onset was as follows: 

1-10 years • 15 cases 41-50 years 28 cases 

11-20 30 " 51-60 : 18 

21-30 ..-■ 33 . " 6l ~7o " • 6 

31-40 " 28 " 71-80 " 2 

Localization. — At the Long Island Hospital the joints were involved 

in the first attack in the following order of 
frequency, according to statistics prepared 



1 




j by Dr. F. S. Richardson : 

f Wrist and hand 15 

Elbow 1 

f. ■, & 

Shoulder 10 

Spine 2 

Hip 1 

Knee 25 

Ankle and feet 6 

More than one joint 4 

Unknown 10 

The onset was 

Acute, obliging the patient to go to bed for a few 

/ -V days in 16 

'Y : ;CJ.-'; -jJnKfifc. Subacute in 6 

\»ji^V *j ^jjgHK&ra Insidious in 35 

)\ j^HHHkI Unknown in 16 

V '"^mP^'^' T According to Pribram, 2 the hand was 

| : •• attacked in 29 per cent, the foot in 24, 

I-'S . the knee in 17.7, the shoulder in 11, the 

ankle in 6, the elbow in 3, and the sterno- 
|: clavicle articulum in 1 . 

I • $ . - ' Garrod and Bannatyne give the order 

of frequency as follows : hand, elbow, cer- 
vical region, knee, ankle, jaw, shoulder, 
% !?VL 4 . .JB hip, stern o-clavicular joint. 
fig. 181.— Ankylosis of Knee-joint Symptoms. — Early Symptoms. — The 

Following' Arthritis Deformans, r _,. rr , 

showing osteophytes and ossi- onset of the affection is, as a rule, 
ncation of Ligaments. (Warren gradual, and no characteristic early symp- 

Museum.) 

toms are noted. In a large majority 01 
cases it occurs in older people, and females are more often affected. 
The early symptoms are most often a gradually increasing lack of 
flexibility in certain joints, which is followed by occasional pain 

1 McCrae : Journ. Am. Med Assn., October 8th, 1904, p. 1027. 

2 Alfred Pribram : " Chronischer Gelenkrheumatismus und Osteoarthritis De- 
formans," Wien, 1902. 



ARTHRITIS DEFORMANS. 203^ 

after unusual exertion. Cracking of the joint is heard, which has 
been studied by Blodgett with the aid of a stethoscope. The stiffness 
of the joint when overused in the early stages is most evident after a 
period of rest. In this early stage it may be a long period before the 
disease is recognized, and the symptoms may be confused by a numb- 
ness or crackling or burning sensation in the joint, sometimes associ- 
ated with vasomotor disturbances which cause redness of the skin. In 
a certain number of cases during this early stage, before the marked 
appearance of characteristic changes, a slight elevation of temperature 
and an increase of pulse may be observed, which may persist for some 
time. In addition to the general discomfort, there may be also present 
impairment of the general condition, shown by loss of appetite and 
wakefulness. The gradual increase of the symptoms is accentuated at 
times by slight acute attacks, induced generally by accident or follovv- 




FlG. 182. — Arthritis Deformans in a Child of Ten, of Long Duration. Most of the joints af- 
fected. Showing- enlargement of elbows, wrists, and ankles, and flexion deformity of 
knees. 

ing overuse. Long periods of remission with slight improvement or 
relative quiescence of symptoms often occur, but on the whole the dis- 
ability increases. 

In other cases the invasion is somewhat acute, so that the affection 
resembles what is ordinarily known as acute rheumatism, differing from 
it, however, in the absence of profuse perspiration and markedly high 
temperature. A sensation of swelling and actual swelling of the joint, 
with some pain on movement, with perhaps some limitation of the ex- 
tremes of motion, follow the changes described. 

Swelling. — The swelling varies greatly both in amount and in its 
location. In the milder cases of the most chronic type at an early 
stage little or no swelling is present, this symptom being gradually de- 
veloped later. Swelling of the synovial tissues, with perhaps synovial 
effusion, is likely to be recognized at a comparatively early stage of the 
affection, and is of importance. Later there occurs a fusiform swelling, 
consisting of cedematous periarticular tissues, the capsule, and the liga- 
ments, along with some inflammation of the synovial membrane. 

Stiffness. — The limitation of motion in affected joints is clue partly 



204 



ORTHOPEDIC SURGERY. 



to the mechanical obstructions to motion produced by the pathological 
process, and partly to muscular spasm, which, however, is a much less 
prominent factor than in tuberculous disease, except when the process 
has become extensive. 

Distortion. — This swelling may diminish, leaving the joint distorted 
by the muscular spasm, the cicatricial contraction of some structures, 
and the relaxation of others, 
along with the periarticular 
thickening of the periosteum 
and other tissues which have 
become the seat of bony deposit. 
Distortion of position is usually 
manifest in the flexion of the 





Fig. 183. — Hand in Arthritis Defoi 
mans in a Child Ten Years Old. 



Fig. 184. — Arthritis Deformans in a Child 
Involving nearly all the Joints. Compar- 
ative! v earlv Stage. 



joints, but in the hands the distortion may be manifested as a hyper- 
extension of the fingers, with deviation to the ulnar side in connection 
with the distortion and alteration in the shape of the articular ends of 
the bone. 

Skin and Fascia. — The subcutaneous tissue and the fascia undergo 
changes, which are characterized at first by swelling, which is followed 
by thickening and contraction. In certain places in the fascia, nodules 



ARTHRITIS DEFORMANS. 205 

may be felt, which may be the occasion of great discomfort when they 
occur in the plantar fascia, which is occasionally the case. Bands of 
contracted fascia and subcutaneous thickening in the hands may cause 
a contraction in flexion of the ulnar fingers described by Dupuytren. 

Varieties. — Several varieties of this affection will be met, which 
may be grouped as follows : 

1. Several joints may be involved, with swelling and without marked 
exostoses. This variety attacks all ages, but is more frequently seen 
in the middle-aged or young. This type has been called the polyartie- 




Fig. 185. — Arthritis Deformans following Gonorrhoea. Considerable boggy swelling of and 
effusion into the joints. Ulnar deviation at proximal phalangeal joints. Painful during 
active stage only. (By the courtesy of the Department of Surgical Pathology of the Har- 
vard Medical School.) 

ular, atrophic, or chronic rheumatoid type. It has also been called 
nodular arthritis or arthritis nodosa. 

2. A monarticular type, attacking chiefly the larger joints, may oc- 
cur. In this form exostoses develop and the joint becomes enlarged 
by the abnormal development of bone. The process is of slow devel- 
opment and is seen in older patients or in patients whose tissues may 
be regarded as prematurely senile. This group is called the monartic- 
ular, hypertrophic, or osteoarthritic variety. A sharp distinction be- 
tween these types is not readily made, and they may be regarded as 
different stages of the same process, the first occurring in younger 
cases, the second when the progress is slower and the changes are 
more completely developed. 

3. A third type, more commonly seen in women and children, is 



206 



ORTHOPEDIC SURGERY. 



characterized by a stiffening" of several joints, with synovial swelling 
and a late development of changes in bone. This has been termed the 
fibrinous type, arthrite fibreuse (arthritis fibrosa), and ankylosing 
arthritis. Goldthwait has described this as an infectious type, 1 but 
McCrae 2 is inclined to. believe that it is not improbable that all forms 
may be regarded as infectious or the result of a toxin as yet undiscov- 
ered. For that reason the term infectious has been avoided by us. 

4. A fourth type of the affection is frequently seen in elderly wom- 
en, the chief characteristic of which is to be found in " Heberderis 




Fig. 186. — Hand in Arthritis Deformans, Show- 
ing the Enlargement at the Middle of the 
Middle Finger. (By the courtesy of the De- 
partment of Surgical Pathology of the Har- 
vard Medical School.) 



FIG. 187.— Arthritis Deformans of Long 
Standing (Heberden's Nodes). Marked 
enlargement of the distal phalangeal 
joints. (By the courtesy of the Depart- 
ment of Surgical Pathology of the 
Harvard Medical School.) 



nodes'' This term is applied to a form of arthritis deformans attacking- 
the fingers at the last phalangeal articulation. Pathologically the process 
is the same as that seen in other articulations, namely, fibrous changes 
in the synovial tissues, the formation of pannus and absorption of the 
cartilage, periosteal thickening, periarticular swelling, and later the 
irregular formation of bone, with subluxation and displacement and 
alteration in the direction of the bones forming the joint. 

The earlier writers classed the affection as a form of gout, but, 
although similar distortions are seen in gout, characteristic Heberden's 

'J. E. Goldthwait: Bos. Med. and Sur. Jour , January 28th, 1897, and 1904. 
-McCrae: Jour, of Amer. Med. Association, xliii., 15, pp. 1027-1038. 



ARTHRITIS DEFORMANS. 



207 



nodes do not have chalkstone deposits. The deformity occurs more 
commonly in women than in men, appearing after middle life. It is 
usually accompanied by similar changes in other joints, but it may be 
limited to the finger-joints alone. The fingers are not very painful, 
though there may be in the early stages slight pain and a prickling and 
itching sensation. 

The treatment of these joints is similar to that of the treatment of 
arthritis deformans in other joints, and is both constitutional and local. 
The course of the affection is usually slow, though there may be 
long periods when but little change is noticeable. 

Pathological changes similar to those described above are also seen 
in a chronic joint affection following gonorrhoea, and also after the 

eruptive diseases, such as scarlet fe- 
ver and influenza. These manifesta- 
tions are similar to milder grades of 
arthritis deformans. Whether they 




FIG. 188.— Arthritis Deformans of Long 
Standing- in an Old Woman. Disloca- 
tion of the proximal phalangeal joints. 
Ankylosis of middle and terminal pha- 
langeal joints. (By the courtesy of 
the Department of Surgical Pathology 
of the Harvard Medical School.) 




Fig. 189. — Double Hallux Valgus and Hammer 
Toes. Associated with arthritis deformans. 



should be classified as distinct or whether they are the exciting cause 
of a chronic process which may end in arthritis deformans is not deter- 
mined. They are entirely distinct from the suppurative affections caused 
by pyogenic germ infection, and are perhaps due to the fact that a pre- 
vious infection has weakened the patient, rendering him subject to the 
influences of a toxin or whatever cause develops the changes seen in 
arthritis deformans. 

Diagnosis. — When an adult is affected with a chronic progressive 
affection of several of the joints, accompanied by swelling, slight pain, 
absence of suppuration, and with an increasing deformity and an en- 
largement, partly of bone and partly of the capsule, with distortion, a. 



208 ORTHOPEDIC SURGERY. 

diagnosis of arthritis deformans is easily made. In the less developed 
cases, in which the affection is monarticular or occurs in children, it is 
at times difficult if not impossible, without a careful observation of the 
case, to determine whether the case is tuberculous or not. A diagnosis 
can be made by incision of the joint and inoculation experiments. In 
children as well as in adults chronic non-suppurative polyarticular affec- 
tions are more probably non-tuberculous. 

A diagnosis is aided by an ;r-ray examination, which in advanced tu- 
berculous affections shows marked focal destruction. 

In arthritis deformans the bone may be either thickened or show 
irregular osteophytes if the process is of the eburnating type, or there 
may be an increased translucency if the cellular change has not ad- 
vanced to bone formation. 

Treatment. — The literature of the treatment of this affection has 
been extremely unsatisfactory until recently. The administration of 
iodide of potash, iron, cod-liver oil, and antacid and antirheumatic drugs 
was formerly recommended as a routine treatment. Of late the use- 
lessness of such medicinal treatment has been generally recognized, 
and more rational methods have taken its place. It goes without say- 
ing that an early diagnosis is of importance in order that the patient 
may be placed under proper conditions before the disease has made 
great progress. The treatment should be both constitutional and local. 
Among the constitutional measures one of the most important is diet. 

Diet. — It was formerly supposed that the affection was of a gouty 
nature, and that a meat diet, and especially one including red meat, 
was to be prohibited. This was based upon the theory that the affec- 
tion was of a rheumatic character and due to an excess of uric acid. 
The theory having been disproved, it is now believed that the affection 
is either caused or influenced by malnutrition, and for that reason a re- 
stricted diet is to be avoided. If meat is well digested and is satisfac- 
tory to the patient, it is manifestly better that the patient should not 
be deprived of it. The diet should be carefully looked after in each 
case and should be directed according to the individual digestion of the 
patient. The patient should avoid an excess of every variety of food. 
A starchy diet or a diet containing a great deal of sugar should be 
avoided in case any intestinal disturbance follows. It should be remem- 
bered that it is not only the stomachic but also the intestinal digestion 
which must be watched. As the affection is influenced by the impair- 
ment of the general metabolism, indigestion should be carefully avoided. 
A glass of one of the laxative mineral waters before breakfast is desir- 
able where there is any tendency to constipation. 

Clothing. — The clothing of such patients should be regulated in 
such a way as to furnish a greater protection from sudden changes in 
temperature and to allow absorption without too rapid evaporation of 



ARTHRITIS DEFORMANS. 209 

perspiration. This object is best reached by the use of woollen under- 
garments. 

General Routine. — It is hardly necesary to add that, so far as the 
general conditions go, a regular life under the most favorable surround- 
ings possible is to be aimed at, that extreme fatigue or mental strain is 
to be avoided so far as practicable, and that so far as possible the unfa- 
vorable surroundings and conditions are to be eliminated. The rest of 
the general treatment consists in properly regulating the diet, in pro- 
moting elimination by the skin, kidneys, and intestines, and by the use 
of tonics when required. 

Exercise. — It is particularly important that all means of elimination 
of waste products should be encouraged. It is for this reason neces- 
sary not only that the intestines should be normally active, but it is also 
desirable that both the perspiration and kidneys should have an oppor- 
tunity for free action. As the latter are influenced by increase of 
fluid in the patient's diet, it is to be carefully prescribed. Exercise 
promoting a free perspiration is also desirable. This in weaker patients 
can be done by the judicious use of hot baths and hydrotherapeutics, 
but, where exercise is possible, perspiration which results from muscu- 
lar effort is more beneficial. 

Drugs.— General tonics should be given, in the shape of strychnine 
if a nerve tonic is desired, and in case on blood examination it is found 
that an anaemia exists, iron is indicated. Aspirin has some effect at 
times in relieving pain. 

Local Treatment. 

The object of local treatment is to promote the circulation and to 
stimulate the tissues around the joints which are undergoing a proc- 
ess of change, which must be regarded as a degeneration rather than 
an inflammation. 

Rest. — When the joints are strained and congested, protection from 
strain is desirable, but absolute rest and fixation are to be avoided ex- 
cept temporarily during the existence of acute pain. Even at this stage 
the joints should be rested rather than fixed. 

Treatment by Rest. — When the joints are in an irritated condition, 
as indicated by pain, tenderness, or discomfort during and after motion, 
restriction of use is for a time advisable. This can be furnished by one 
of the mechanical appliances described for preventing joint motion in 
tuberculous diseases of the joints or by the application of a removable 
plaster support. Such restriction of joint motion is to be employed for 
as short a time as possible and to be discontinued as soon as the acute 
stage is past. Motion is to be regarded as a normal function of the 
joint, and degenerative changes take place more quickly in unused 
14 



210 ORTHOPEDIC SURGERY. 

joints, and hence in this condition, prolonged fixation is to be avoided as 
probably detrimental. 

Exercises. — The principle of treatment is that the joints should be 
used within the arc of their possible motion freely, but that strain, vio- 
lence, and excessive use should be avoided. As far as possible the arc 
of motion should be increased, but this should not be done at the ex- 
pense of irritating the joint. Exercises for the purpose just described 
can be given in the form of passive manual manipulation or by the aid 
of such mechanical appliances as have been devised for the purpose of 
moving the joint without the use of the muscles. These should not be 
pushed to the point of causing much pain. Various forms of pendulum 
exercises can be employed and the well-known Zander appliances are to 
be used, but, being complicated and expensive, they are beyond the 
reach of general practitioners. Simple apparatus can be devised which 
will answer this same purpose. As the joints improve, carefully pre- 
scribed active exercises can be added to and take the place of the pas- 
sive exercises. Exercises, either active or passive, given for this 
purpose, are best done when the body weight is removed from the 
joint. 

Hot Air. Local. — The local application of dry, hot air, carried to a 
point of from 300° to 400 F., has proved to be of benefit in the treat- 
ment of arthritis deformans in many instances, especially in the lighter 
cases. The limb should be placed in a properly constructed oven, 
wrapped in flannel, and the heat raised to the highest comfortable 
point. This treatment should continue from twenty minutes to an 
hour. The treatment, although often productive of great benefit, 
should be applied with discretion and the patient watched, as it is at 
times exhausting and may irritate the joint. In the stage of acute 
inflammation it is not so beneficial as at other times. The heating of 
the joint should be followed by rest, and, in cases that are not acute, 
massage following the heating may be of use. 

Hot Air. General. — Hot-air baths for the whole body may be 
given by means of a metal cylinder lined with asbestos, which is 
long enough to include the body up to the armpits and is heated by 
gas, gasoline, or electricity. The patient lies in the cylinder and the 
temperature is raised to 350 or 400 . The heat should be run up rap- 
idly in order to secure the necessary degree of physiological effect as 
quickly as possible. The pulse and temperature rise, and an exposure 
to this heat from twenty to twenty-five minutes is sufficient. The 
method is described as being of greater use than the local application, 
and is suited to the treatment of the severer cases. 

Electric Light Baths. — The use of the combined heat and light 
given off by a number of incandescent electric light bulbs, placed inside 
of a box similar to the ordinary cabinet bath, has been found of use. It 



ARTHRITIS DEFORMANS. 2i'l 

is said that free perspiration is induced at a lower temperature than 
when the heat alone is used without the light. 

Massage— Manual massage is of assistance in stimulating the local 
circulation and promoting the absorption of some of the swelling. It is 
a remedy often of use, but sometimes exaggerates the symptoms. It 
should be used with great gentleness, and the joint, if acutely irritated, 
should be very lightly rubbed, the attention being directed to the tis- 
sues about the joint. As the tolerance of the joint increases it may 
receive more massage, but many cases are rendered more acute and 
painful by the use of massage applied for too long a time. It is useful 
only in so far as it is quieting to symptoms, and should be done with 
gentle passive movements. Mechanical vibratory stimulation is of use 
in connection with, or replacing massage. It may be given as a general 
treatment for purposes of stimulation, and locally it serves as a sedative 
to muscular irritability. 

Electricity. — Electricity may be of use in the form of galvanism ap- 
plied once or twice weekly, or of static electrical application made more 
often. The Morton wave current and some of the high-frequency cur- 
rents applied either locally or generally may be of use with these or 
may replace them. 1 

Hydrotherapy. — The use of hydrotherapy in this disease is at times 
of undoubted benefit. The combination of a change in surroundings, 
careful diet, and massage, in connection with the water treatment, fre- 
quently unite in improving the patient's general and local condition. 
The use of warm alkaline baths may be varied by the use of baths of 
hot mud, a mode of treatment for which special arrangements are nec- 
essary. The subject of hydrotherapy is too extensive to be entered 
upon here,' 2 and in the treatment of arthritis deformans it is to be re- 
garded as a measure for both general and local treatment, at times of 
much value. The recent establishment of hydrotherapeutic institutions 
in the larger cities serves to make this treatment more available. 3 

Treatment by the Application of Hot Sand. — Burying the affected 
joint in hot sand is a method of applying dry heat. The heat cannot 
be as well regulated as the hot-air treatment, but it will be found to be 
efficacious. 

Vacuum Treatment. — Placing the joint within a glass case and ex- 
hausting the air by means of a pump has been tried with benefit in sev- 
eral cases. It is a means of causing passive hyperemia. 

Treatment by Passive Congestion. — Bier has recommended a method 
of treating arthritis deformans which is specially applicable for the knee 
and wrist. This consists of setting up a local passive congestion, which 

1 Skinner: Jour. Amer. Med. Assn., October 8th, 1904. 
- Baruch : "Hydrotherapy," New York, 1899. 
3 Pratt : Boston Medical and Surg. Journ. , 1904. 



2 12 ORTHOPEDIC SURGERY. 

can be accomplished by applying a bandage from the foot up to the 
knee, leaving the knee uncovered and applying an elastic bandage di- 
rectly above the knee, sufficiently tight to cause a congestion of the 
joint. This congestion should not be so great as to give rise to a cold 
condition of the surface. The tissues should become blue and the pa- 
tient should suffer some discomfort, but pain should not be experienced. 
This congestion should be allowed to continue for from seven minutes 
to half an hour, and massage should be applied to the joints afterward. 
The method is of advantage, but does not take the place of dry heat, 
though it may be used in certain cases in which dry heat is not applica- 
ble. 1 

Operative Treatment. 

As functional use of a joint affected with deformity is essential to 
recovery, when deformities exist in the lower extremity one of two 
things is necessary. Either the limb must be straightened by appara- 
tus or by operative means, unless gymnastic exercises and stretching 
can be used for the purpose. 

Mechanical Correction of Deformities. — The same methods that are 
used in the correction of deformities of tuberculous disease can also be 
applied to the deformities following arthritis deformans, with the excep- 
tion that the latter occurs more commonly in adults than in children 
and greater difficulty is met in correcting these deformities without an 
anaesthetic. On the other hand, greater force can be used without 
danger of suppuration in arthritis deformans than is possible in the 
tuberculous affections. 

Removal of Obstructions. — The operation consists of forcible correc- 
tion with or without tenotomy, after the removal of any obstructive 
fringes or lipomata if such interfere with the motion of the joint, or the 
removal of exostoses if these act as obstructions. It is manifest that 
when many joints are involved operative interference is to be limited 
to the most important joints or the joints most important for loco- 
motion. 

Goldthwaite and Painter have demonstrated by their work the feasi- 
bility of opening the knee-joint and removing obstructing fringes, and 
it is manifest that where an exostosis prevents motion, and its removal 
will improve the function of the joint, it is desirable that it should be 
done. It should, however, be remembered that in many of these the 
affection is not simply limited to an alteration in the synovial mem- 
brane. 

Summary. — The less severe cases are likely to be relieved by being 
put upon a proper regimen in the matter of diet, exercise, sleep, baths, 

1 A. H. Freiberg: Amer. Jour, of Orth. Sur. , vol. ii., No. i, p. 50. 



ARTHRITIS DEFORMANS. 213 

etc. In addition to this, electricity, massage, douches, hot-air baths, 
and the other methods intended to improve the local circulation are 
likely to be highly beneficial. 

The severer cases demand more careful treatment and supervision, 
and the following will serve as the type of a desirable routine : The 
diet should be generous. The patient should rest in bed ten out of the 
twenty-four hours. Tonics and mineral waters are used. Hot-air or 
electric-light baths to the whole body are given two or three times 
weekly. Electricity or vibratory stimulation is given practically daily. 
Passive movements are given to the affected joints with a view to in- 
creasing their range of motion. 

The treatment of arthritis deformans in its various stages requires 
not only patience on the part of the surgeon, but much care on the 
part of the patient. Relief can be offered in almost all instances, and a 
stay of symptoms may be expected to follow in a certain number of 
favorable cases. It is to be remembered that the affection is essentially 
chronic and that the natural course of the disease is interrupted by as 
yet unexplained periods of remission. It is, therefore, difficult to ex- 
amine critically the principles of treatment or the results in any indi- 
vidual case, but it is certain that attention to the patient's general con- 
dition, followed by the improvement which is brought about by such 
measures as are influential in improving the circulation, makes the use 
of the limbs possible with less discomfort ; the correction of deformity, 
the protection of the limb from strain, and the placing of the limb in 
such a position, by operation or by apparatus, that locomotion is not 
accompanied by discomfort, unite in aiding the joint to recover its 
usefulness. 

Arthritis Deformans in Children. 

In children the characteristics of the disease do not vary essentially 
from those in adults. Clinically one finds the same type of manifesta- 
tions seen in adults in some cases, while others show a type chiefly 
found in young children, which was described among others by Still 
and is sometimes spoken of as Still's disease. 1 In such cases the symp- 
toms begin generally before the second dentition, the earliest onset 
reported being in a child fifteen months old. In this type the cartilagin- 
ous and bony changes are slight, and progressive and deforming swell- 
ing with thickening of the joint and periarticular structures takes 
place. The affection is polyarticular ; pain is not a predominant symp- 
tom, but glandular and splenic enlargement is common. Recovery may 
occur in these cases. The treatment does not vary from that in adults. 

1 Still: Med.-Chir. Trans., 1897.— Spitzy : Zeit. f. Orth. Chir., xl., 4, 699 (with 
bibliography).— Gold thwaite : "Infectious Arthritis." Boston Med. and Surg. 
Journ., 1904. 



214 ORTHOPEDIC SURGERY. 

SPINE. 
Spondylitis Deformans. 

Osteoarthritis of the spine, 1 ankylosing inflammation of the spine, 2 
rigidity of the spine, spondylose rhizomelique, 3 neuropathic curvature 
of the spinal column, 4 kyphose heredo-traumatique, Bechterew's dis- 
ease of the spine, 5 Steifigkeit der Wirbelsaule, etc., are names which 
have been applied to the condition. 

The essential character of this affection is a chronic and progressive 
stiffening of the spine, accompanied by pain. 

Pathology and Etiology. — When the process involves the spine the 
same differences in types may be seen as those described. The affec- 
tion may be characterized by stiffness without much bony change, 
or the bony change may be marked and the deformity distressingly no- 
ticeable. When the spine is completely stiffened it is accompanied 
usually by some loss of motion in the articulations of the rib, corre- 
sponding to the fibrinous arthritis or ankylosing arthritis seen in other 
joints. 

The pathological process found is that of arthritis deformans modi- 
fied by the peculiar structure of the vertebral column. The ligaments 
and interarticular cartilages degenerate, and the former become the 
seat of bony deposits, while the latter may hypertrophy at the edges 
and these marginal hypertrophies become ossified, forming a lipped 
edge to the vertebra. The interarticular cartilages degenerate and the 
vertebrae become fused together. A deposit of new-formed bone occurs 
along the front and sides of the column, binding the various vertebrae 
together. 

In other cases the hypertrophic element is wanting and fusion of 
the vertebrae occurs by disappearance of the intervertebral discs without 
marked deposit of new bone. 

The hips and shoulders are involved in the process in a certain 
proportion of cases, showing the changes characteristic of arthritis de- 
formans. The peripheral joints may or may not be simultaneously 
affected. 

The etiology is not different from that of arthritis deformans else- 

1 Goldthwaite : Bost. Med. and Surg. Journ., 1902, p. 299. 
2 Striimpell: Deut. Zeit. f. Nervenheilkde., 1897, 338. 

3 Marie : Revue de Med., 1898, xviii., 285. — Vollheim : Inaug. Dissertation, 
Jena, 1902. — Siven: Zeit. f. klin. Med., xlix. — Rurah : Am. Journ. Med. Sci., 
November, 1903 (with bibliography). — Simmonds : Fortsch. a. d. Gebiete d. Roent- 
genstr. , vii., 2. — Brodnitz : Zeitsch. f. orth. Chir. , xii., 142. — Pribram: " Chr. 
Gelenkrheumatismus," etc., Wien, 1902, p. 158 (with bibliography). 

4 Neurol. Centralbl., 1899, vii., 294. 

"Neurol. Centralbl., 1893, 426; Deutsch. Zeit. f. Unfhkde.. 1S97. xl -i 3 2 &- 



ARTHRITIS DEFORMANS. 



215 



where, except that gonorrhoea seems to be quite frequently an antece- 
dent of the affection. 1 

There has been a tendency to recognize two types of the affection: 



Flexion Forward. 
IT 



Flexion to Left. 
Ill 




IV II 

Flexion to Right. Best Standing Position. 

FIG. 190. — Arthritis Deformans. Involving spine from upper dorsal to mid-lumbar region 

(J. E. Goldthwaite.) 

(1) described as the Bechterew type, 2 in which the other joints are gen- 
erally not affected, and in which a neuropathic origin has been assumed 

Bradford: Ann. of Anat. and Surg., 1883, vii.. 6. 

2 Striimpell : Deutsch. Zeit. f. Xervenheilkunde. 1897. iv. 



216 



ORTHOPEDIC SURGERY. 



to exist; (2) the Striimpell-Marie type/ with involvement of shoulders 
or hips, and in this type the pathological basis is found in an ankylosis 
of vertebrae and an ossification of ligaments. 

Later consideration of the subject has tended to the opinion that 
the two types are not distinct, but simply the natural variations of a 

process which is characterized 
in general by marked differ- 
ences in its manifestations. 

Symptoms. — Stiffness and 
pain in the spine are the char- 
acteristic symptoms. Stiff- 
ness at first is partly due to 
muscular irritability, but later 
may become the result of an- 
kylosis. 

Motion is generally re- 
stricted in all directions, but 
bending to one side is freer 
than to the other at first. 
Lateral deviation of the spine 
is likely to be present. The 
physiological dorsal curve may 
be increased and the lumbar 
curve generally obliterated, 
after a while the whole spine 
forming a bow backward. The 
gait is careful and simulates 
that of Pott's disease. 

Pain is present chiefly in 
the spine, but also in the per- 
ipheral ends of the nerves, as 
in Pott's disease. It is gener- 
ally more marked on one side 
than on the other. It may be 
a subordinate symptom or it 
may be so acute as to be ag- 
gravated by every jar, and it 
may be paroxysmal. Pains of a neuralgic character, areas of disturbed 
sensation, and even paralysis may be present in the legs and arms. 
These are due to the compression of the nerve roots. 

The patient walks more or less bent over by the dorsal kyphosis, 
and in stooping the motion is entirely from the hips. In lying down 
the curves are not affected or obliterated in the later stages. The lower 
1 Bechterew : Deutsch. Zeit. f. Nervenheilkunde, 1899, xv. 




FlG. 191.— Arthritis Deformans Following Gonor- 
rhoea Involving Spine and Many Other Joints. 
Spine perfectly rigid except upper cervical re- 
gion. (By the courtesy of the Department of 
Surgical Pathology of the Harvard Medical 
School.) 



ARTHRITIS DEFORMAXS. 2\J 

spine is generally first affected and the cervical last. In the severest 
cases the spine is stiff from the sacrum to the occiput, and permits no 
more motion than would an iron rod. In the severer cases the ribs are 
ankylosed at their junction with the spine, and the chest wall scarcely 
moves in inspiration, or it may be entirely stationary and the breathing 
is wholly abdominal. As the cervical vertebrae are usually the last to 
be affected, motion of the head may be possible after the dorsal and 
lumbar regions have become rigid. In less severe cases the spine is not 
involved to the whole extent, but marked stiffness without angular pro- 
jection exists in a portion of the column. Stiffening and flexion of the 
hips is present in some of the cases, and leads to a most distressing 
gait in which the whole body is carried bent forward. 

The course of the disease is chronic in the extreme, and its duration 
covers many years. The bone inflammation has no destructive ten- 
dency and accomplishes nothing more than stiffening the vertebral col- 
umn. The impairment of the general health consequent upon this is 
generally not so severe as one would anticipate. 

The diagnosis of the affection can be made by recognizing the ri- 
gidity of the entire vertebral column without the angular prominence of 
Pott's disease, nor does the latter affection so stiffen the whole column, 
but only the diseased region. Pott's disease involving the whole or a 
large portion of the vertebral column would soon lead to very marked 
results in its destructive tendency. The immobility of the ribs is a 
pathognomonic sign of the affection, and the involvement of other 
joints would merely confirm one's opinion of the character of the dis- 
ease. 

Prognosis. — It need hardly be said that the prognosis is unfavorable 
as to complete recovery. Early cases may pass into a quiescent stage 
by means of proper treatment and the pain subsides. Most cases are 
improved by support and fixation. If the other joints are involved, the 
patient's condition is deplorable. 

Treatment. — The general measures likely to be of use have been 
described. In the acute stage the use of fixation is indicated. A plas- 
ter or leather jacket applied without suspension is the best means of 
obtaining this. As the acute symptoms quiet down, massage is of 
value. The spine should be protected by a brace so long as it is pain- 
ful and irritable. The use of manipulation to ward off the approaching 
ankylosis is harmful and undesirable at all stages of the affection. 

HIP. 

Arthritis deformans of the hip-joint is an affection which is not un- 
common in patients above the age of forty -five. It may occur as a 
monarticular affection or in connection with a simultaneous affection 
of some of the other joints. 



218 ORTHOPEDIC SURGERY. 

Pathology and Etiology. — When affecting the hip it is known as 
senile coxitis, malum coxae senile, etc. It begins in many cases insidi- 
ously, while in others, and especially monarticular cases, it follows after 
a fall upon the trochanter. From the shortening of the head and neck 
in these cases it was long supposed to be an impacted fracture of the 
neck of the femur, but the shortening results from the absorption of 
the head and is in every way like the pathological changes found in the 
insidious cases. The affection may occur in adolescents and children. 1 

Symptoms.— The affection begins with pain in and about the joint, 
often shooting down the course of the sciatic nerve at the back of the 
leg instead of down the front, as in epiphyseal ostitis. At this stage 
the affection very closely simulates sciatic neuralgia. Movements of 
the joint beyond a certain arc are painful, and a noticeable limp is pres- 
ent. External rotation and hyperextension are particularly painful 
movements to the patient, and if the leg is manipulated a distinct creak- 
ing is sometimes felt which is most noticeable when the movements are 
most painful. 

Muscular atrophy of the limb comes on and the nates of the affected 
side are flaccid and flattened, and apparent shortening from flexion and 
adduction is present in the diseased limb, as well as true bone shorten- 
ing. Muscular fixation is at first not a prominent symptom, except in 
very sensitive conditions of the joint, but the arc of motion gradually 
diminishes, until finally the joint may become entirely stiff in perhaps 
a normal position, or perhaps adducted or flexed. In the earlier stages 
abduction and apparent lengthening of the limb may be present as in 
hip disease. 

The position which the limb assumes in the more advanced cases of 
the disease is one which is calculated to be most misleading, especially 
when the affection has followed a fall upon the trochanter. The limb 
may be rotated outward and, with the apparent shortening, presents al- 
most a complete picture of an impacted fracture of the neck of the femur. 
In other instances the thigh may be flexed and adducted as in hip dis- 
ease proper. 

Diagnosis. — The affection is likely to be confused with sciatica and 
with other forms of inflammation of the hip-joint. 

In sciatica the limitation of motion is governed by the amount of 
pain produced by the movement of the sensitive parts and by the ten- 
sion on the nerve, and therefore differs from that resulting from true 
hip-joint disease. Flexion is usually free to a certain limit, but impos- 
sible beyond this, and if the leg is held extended on the thigh this is 
particularly noticeable. In sciatica, hyperextension is not interfered 
with, nor rotation nor lateral motion. The diagnosis from true hip dis- 
ease is based on the history of the affection, the ;r-ray appearances, and 
1 Bruns : Beitr. z. klin. Chir. , xl., 650. 



ARTHRITIS DEFORMANS. 219 

on the patient's age— tuberculous epiphyseal ostitis being less common 
in adults. 

Treatment. — Morbus coxae senilis or arthritis deformans demands 
treatment, first to relieve the pain, and secondly to correct the deform- 

The symptom of pain is rarely so great as to cause disability. In 
such cases hot baths, massage, galvanism, hot packs, and the other 
measures mentioned are often of use. The use of crutches and canes 
will often be needed. The deformities which follow this affection are 
usually those seen in hip disease, but they are more gradual in devel- 
opment. They are persistent and obstinate, but are amenable to proper 
mechanical treatment, such as is used in the deformities of hip disease. 1 

Joint irritation from overuse is to be met here as elsewhere by rest 
to the joint. The use of the protection splint described in hip disease 
may temporarily be necessary when the joint is acutely irritated. 

More is to be gained ordinarily by gradual correction by mechanical 
means than by forcible straightening in this class of affections of the 
hip. 

KNEE. 

The knee is one of the large joints most frequently attacked by this 
affection. 

Symptoms. — Pain, irritability, and a sense of stiffness, especially 
after sitting a while, are the most frequent early symptoms. After 
walking a while the knees feel freer, but they stiffen up after rest and 
are also painful in the morning on waking. Going up- and down-stairs 
is difficult and irritating. The whole condition at first seems rather an 
irritability than anything more serious, and the patient is apt to disre- 
gard the discomfort and to do considerable walking, on the ground that 
walking relieves the stiffness. The discomfort is increased by cold and 
wet and by overuse. Acute attacks of pain and swelling may occur. 

In some cases the affection progresses insidiously and gradually 
without acute attacks. On examination in the early cases the synovial 
membrane is somewhat thickened and the surface depressions of the 
knee are filled out. There is perhaps a little fluid in the joint, and 
movements are almost always attended by a more or less marked grat- 
ing. This phenomenon is due chiefly to hypertrophy of the synovial 
fringes, which are rubbed together when the joint is moved. It is also 
probable that the same sensation can be produced without any struct- 
ural change by mere dryness of the articular surfaces. 

In the progressive cases and in those of longer standing the painful 
symptoms are more marked, and heat and tenderness are prominent, 
according to the acuteness of the symptoms. 

J " Senile Coxitis." N. Y. Med. Jour . December 15th, 1888. 



220 



ORTHOPEDIC SURGERY. 



At times there is on walking a sensation of catching in the knee, as 
if something had been squeezed between the bones. This points to an 
hypertrophied condition of the synovial fringes. 

The first limitation of motion is a resistance to complete extension, 
and the tendency to a flexed position is marked, favoring ankylosis in 
this position. 

In general, the tendency of the affection is toward greater and 




Fig. 192.— Enlargement of Knees and Ankles from Arthritis Deformans in a Child of Ten. 

Disease of long duration. 



greater impairment of the joint motion, with wasting of the muscles 
and atrophy of the skin, so that in the advanced stages one can see a 
stretched and shining skin tightly drawn over the deformed and dis- 
torted joint. 

The prognosis depends largely upon the degree of change in the 
joint surface when treatment is begun. If it is slight, as shown by 



ARTHRITIS DEFORMANS. 



221 



moderate thickening and soft grating on motion, much is to be expected 
from the prevention of overuse and the regulation of the circulation in 
the knee. If the changes in the joint are advanced, and especially if 
other joints are showing signs of a progressive involvement, the out- 
look is unfavorable; not that life is likely to be shortened, but that 
serious disability of the joint most often results. 

Treatment When pain is present rest is very strongly indicated. 

A few days will generally suffice to quiet the acute symptoms. Dur- 




FiG. 193.— Arthritis Deformans, Bony Enlargement of Knees with Effusion. Palpable fringes. 
Limitation of motion. Crepitus and pain on motion. (By the courtesy of the Department 
of Surgical Pathology of the Harvard Medical School.) 



ing the quiescent stage, the local measures described above should 
be used. If pain is excessive, one has to face the dilemma of continu- 
ing motion which is excessively painful or of allowing the patient to 
rest and keep the joint still, by which process one is likely to favor the 
stiffening of the joint, if it is continued for too long a time. For short 
periods, however, there is no risk, and sometimes much to be gained by 
complete rest to the affected articulation. 



222 



ORTHOPEDIC SURGERY. 



When ankylosis of the knee in a faulty position has resulted from 
arthritis deformans, brisement force is to be tried for its rectification, 
as described for the correction of ankylosis after tumor albus. It is 
not, of course, to be expected that motion will be present in the joint 
in its new position, for. the structural changes must have already been 

extensive to have induced the de- 
forming ankylosis, yet some motion 
may be preserved in the joint. 

SHOULDER. 

The shoulder is a frequent seat 
of this disease, when it occurs in the 
monarticular form. When one shoul- 
der alone is affected the history of 
injury is usual, but in the polyartic- 
ular forms this is not so common. 
The disease may first manifest itself 
to the patient as a slight attack of 
joint pain, tenderness, and stiffness, 
and from this condition pass into 
the slow chronic course, with occa- 
sional exacerbations, or it may begin 
insidiously. The amount of pain 
varies ; it is more or less persistent, 
but not constant, and is dull and 
heavy and usually worse at night. 
Stiffness appears at this time with 
pain, at first only slight, and noticed 
in forced movements, when the arm 
is raised above the level of the 
shoulder. 

As the disease progresses the 
muscles waste, and in severe cases 
to a very noticeable degree. A creak- 
ing sensation, both on active and passive motion, is almost always found 
by placing the hand over the joint. Later in the disease, when the 
characteristic osseous changes occur, the arm can be raised but a short 
distance from the side, and the loss of muscular power is great. When 
the changes in the joint have taken place a characteristic appearance of 
the joint is found. The head of the humerus is more prominent in 
front of the joint, while behind is a depression as if the head of the 
bone was displaced forward, while the shoulder droops. 

The treatment does not differ from that described for the other 
joints. 




FlG. 194.— Arthritis Deformans Following 
Gonorrhoea. Effusion into left knee-joint 
with subluxation of the tibia. Consider- 
able thickening of soft parts. Motion 
mostly limited by pain. [Involvement 
of many joints.] (By the courtesy of the 
Department of Surgical Pathology of the 
Harvard Medical School.) 



ARTHRITIS DEFORMANS. 223 



WRIST. 



The wrist is a common seat of this affection, with the ordinary 
symptoms of pain, swelling, stiffness, creaking, etc. When deformity 
has occurred, the wrist is generally flexed, and the distal ends of the 
radius and ulna are enlarged and project backward. Frequently the 
hand is adducted, this often being associated with a similar distortion 
of the fingers. 

Arthritis deformans of the wrist should be treated on the principles 
already indicated for these affections. 

The tcmporo-maxillary joint is occasionally affected by arthritis de- 
formans. Massage in these cases can be given by the finger in the 
mouth, as the affected joint is more easily reached from the inside. 



CHAPTER VIII. 
OTHER AFFECTIONS OF THE BONES AND JOINTS. 

Sprains. — Spine. — Spondylitis traumatica. — Rupture of spinal ligaments. — Hip. — 
Knee. — Lesions of the tubercle of the tibia.— Ankle.— Wrist. 

Chronic synovitis. — Hip. — Knee.— Hypertrophy of villi. — Loose bodies. — Lipoma. 
— Dislocation of semilunar cartilages. — Cysts. — Trigger knee. — Irritability 
secondary to flat-foot. — Ankle.— Shoulder. — Elbow. — Wrist. 

Bursitis. — Hip. — Knee. 

Habitual dislocations. — Patella. — Shoulder. — Symphysis pubis. 

Tumors of bones and joints.— Syphilis. — Spine. — Gout. — Ostitis deformans. 

Arthropathy. — Spine. — Hip. 

Haemophilia. — Scurvy. — Secondary osteoarthropathy.— Growing pains. 

Actinomycosis. — Spine. — Myositis ossificans. — Ankylosis. 

SPRAINS. 

The name sprain is used to designate a common condition caused 
by wrenches and twists, and occasionally by blows to the joints. It is, 
in general, the result of some sudden force moving the joint beyond its 
normal arc of motion. The injury may be most marked: (i) to the 
ligaments, which may be injured or torn ; (2) to the synovial membrane, 
which may become the seat of an acute synovitis; or (3) to the tendons 
surrounding the joint, causing a tenosynovitis. Any one of these or 
any combination of them may exist in a given case. 

The pathology of the affection requires no especial consideration, 
the changes found being simply those of reaction to trauma modified 
by the especial tissue affected. 

The symptoms consist of pain, more or less severe, and tenderness, 
localized at the point of the chief injury; in the more superficial joints 
ecchymosis of the subcutaneous tissue appears, followed by swelling. 
The function of the joint is accompanied by pain, often severe enough 
to prevent its use. A period of greater or less disability follows, dur- 
ing which the symptoms diminish in severity, and in favorable cases 
entirely disappear. In other cases a condition of swelling, irritability, 
and impaired function persists, spoken of as " chronic sprain." Sprains 
are not frequent in children, in comparison to adults. 

The joints most frequently sprained are the ankle and wrist. 

The diagnosis from fractures is important and is to be made with 
great care. 

The prognosis is favorable and progress is hastened by treatment. 

Two lines of treatment are recognized. In one the joint is fixed by 
a splint or plaster bandage, and disuse of the joint is depended upon to 

224 



OTHER AFFECTIONS OF BONES AND JOINTS. 225 

hasten repair and the absorption of the blood and serum poured out. 
When the process has passed the acute stage, massage and douches 
are generally used to stimulate the circulation and hasten recovery. 

In the other method of treatment the attempt is made directly 
after the injury to stimulate the local circulation by massage, etc., and 
thus hasten the repair while the joint is used in moderation. The lat- 
ter method is painful, but recovery seems to be hastened by it, and the 
circumstances of the patient are frequently the determining factor in 
the choice of methods. 

The latter method is carried out as follows : Immediately after in- 
jury the joint should be baked in a hot-air oven for half an hour and 
massaged for a few minutes, or massage alone should be given as soon 
after the accident as possible. Massage should then be given twice a 
day for periods of half an hour each, which at first will be decidedly 
painful, and the joint should be used moderately. During the early 
part of the treatment the joint should be supported by an elastic flan- 
nel bandage or adhesive plaster strapping. The massage periods should 
gradually be separated by longer intervals, and may alternate with 
douches of hot followed by cold water to the affected joint. Various 
modifications of the treatment maybe used; hot-air baths may take the 
place of one daily massage treatment in the early stages. Vibratory 
massage is of use. 

When massage follows the treatment by immobilization, the method 
does not differ from that described. 

Spine. 

Sprains of the Spine. — After a severe wrench or twist of the spine 
•or after some accident causing extreme motion in one or another direc- 
tion, a condition of pain and disability ensues, presenting much the same 
symptoms as those accompanying sprains in the other joints. Stiff- 
ness, pain, and perhaps lateral deviation follow a painful period, during 
which recumbency is generally necessary. As such cases are most often 
treated by recumbency on a sagging mattress, followed by sitting up as 
soon as possible, these cases are apt to drag on through a long conva- 
lescence and often to pass into the chronic condition described as " neur- 
asthenic spine." It is better that cases with this history should be 
recognized as chronic sprain of the spine, to which nervous symptoms 
have been added. 

When the chronic stage has been reached there is but little ten- 
dency to spontaneous improvement, and the diagnosis from spondylitis 
deformans may be difficult. 

The treatment of sprains of the spine should consist in the immedi- 
ate application of a plaster jacket or recumbency on a gas-pipe frame 
until convalescence is established. Then should follow massage and 
15 



226 ORTHOPEDIC SURGERY. 

progressive use of the spine, protected by the jacket or a spinal support 
as long as movement is painful. 

If the patient has reached the stage of chronic irritability of the 
spine, fixation by a jacket is indicated, followed by the course of treat- 
ment just described for convalescent cases. 

Traumatic Spondylitis. — Following accident some weeks or months 
after, there develops at times a painful and stiffened condition of the 
spinal column, accompanied by a rounded kyphus of greater or less ex- 
tent, which remains as a permanent condition. Partial paralysis may 
occur. 

Kiimmell, 1 who originally described the affection, assumed that 
there existed a rarefying osteitis, but this assumption has not been 
sufficiently supported by post-mortem evidence, and it seems likely 
that the condition is the outcome of partial and compression fractures 2 
of the vertebral bodies and changes in the shape of the bodies induced 
by their altered static relations. 3 Certain cases described under this 
heading are perhaps cases of arthritis deformans following trauma and 
wrongly classified, and some may be classed in all probability as osteo- 
myelitis. The prognosis does not differ from that of spondylitis defor- 
mans. The treatment consists in rest and fixation of the spine. 

Rupture of Spinal Ligaments. — By severe traumatism to the back, 
causing extreme flexion < f the spine, there may occur a rupture of the 
posterior spinal ligaments between two of the vertebrae. 4 A kyphus is 
present in the erect position, which disappears on lying down. It is 
accompanied by pain, which is more acute in the upright position. The 
diagnosis is made from the signs described. The treatment consists in 
fixation of the spine by a brace or jacket in the corrected position. 

Hip. 

Sprains of the hip are manifested clinically as synovitis of that joint 
and are described in that connection. 

Knee. 

On account of the strength of the muscles and ligaments controlling 
the joint, gross ligamentous and muscular injury is rare at this joint, 
the results of trauma being generally expressed as synovitis. 

Lesions of the tubercle of the tibia have been described by Osgood,"" 
in which, after a sudden strain falling upon the partially extended 
knee, swelling and tenderness of the tubercle have followed, associated 

1 Deut. med. Woch , 1895. 

-Reuter: Arch. f. orth. Chir., ii., 2, 137 (with full bibliography). 
3 W. A. Lane: Practitioner, May, 1901. 

4 Painter and Osgood: Boston Med. and Surg. Journ., January 2d, 1902 (with 
bibliography). 

6 R. B. Osgood: Boston Med. and Surg Journal, January 29th, 1903. 



OTHER AFFECTIONS OF BONES AND JOINTS. 227 

with pain on complete extension of the leg. The condition is seen 
chiefly in boys at or about the age of puberty. 

This condition would seem to be due in some cases to an inflamma- 
tion of the bursa under the patella tendon, 1 and in others to an injury 
of the partly ossified and vascular epiphysis of the tubercle of the tibia. 
Jf-ray appearances are apt to be misleading, as during the normal ossi- 
fication at this age the tubercle appears to be torn loose from the tibia 
below. 2 Only when there is a marked difference in the radiographs of 
the two knees and the tibial tubercle is displaced upward is one justified 
in diagnosticating any displacement of it by force. The treatment con- 
sists of fixation. 

Ankle. 

On account of its flexibility and its constant liability to twists, the 
ankle is the commonest location of sprains. These may take the form 
of injury to the ligaments, the joint membrane, or the tendons. The 
location of the tenderness, swelling, and pain on manipulation will serve 
to identify the anatomical location of the injury. 

The treatment consists either in fixation in a stiff bandage or, what 
is in most cases advisable, in immediate massage or hot-air baths, or 
both. Massage should at first be given twice a day, and should be 
deep and thorough. Moderate use of the foot in walking is desirable 
from the first, except when it is excessively painful or when there is 
severe ligamentous injury. Walking may be rendered less painful by 
the use of the adhesive plaster strapping described. As improvement 
progresses the massage is given less often and douches of alternating 
hot and cold water are added or substituted. 

Chronic Sprain. — In many cases the treatment is too soon discon- 
tinued after sprains, and a tenosynovitis or subacute inflammation of 
part of the synovial sac may persist and be accompanied by local heat 
and tenderness. It matters not so much how long after a sprain local 
heat is found in the ankle-joint ; it is a most important sign and indi- 
cates the need of rest. 

In other cases fixation has been continued too long, and wasting of 
the muscles and disturbance of the local circulation and innervation 
have induced a condition of irritability. 

In such cases the treatment consists of measures to stimulate the 
local circulation and the careful and graduated resumption of use. 

Wrist. 

Sprains of the wrist may affect either tendons, ligaments, or synovial 
membrane. The treatment does not differ from that already described. 
The sprains of other joints do not require especial mention. 

1 Lovett: Report Boston City Hospital, series viii., 1897, p. 345. 
-R. W. Lovett: Phila. Med. Journ , January 6th, 1900. 



22 8 ORTHOPEDIC SURGERY. 



CHRONIC SYNOVITIS. 



Chronic serous synovitis is also known by the names of dropsy of the 
joint, hydrarthros, hydrarthrosis, hydrops articulorum chronicus, etc. 
As a rule, pathological changes are present in the synovial membrane 
of a character about to be described ; but certain cases show no obvious 
pathological changes beyond increase of fluid for a long time. 

Apart from the cases in which chronic serous synovitis is (i) merely 
the continuance of the acute condition, its cause is to be sought (2) in 
the presence of some mechanical irritation (such as hypertrophied syno- 
vial fringes, loose bodies, etc.), (3) in the presence of some infectious 
process (such as gonorrhoea or syphilis), or (4) in connection with some 
general disturbance (such as arthritis deformans, haemophilia, etc.). 
Intermittent synovitis should be mentioned as not coming under any 
one of these heads. 

The pathological changes in simple chronic synovitis are represented 
by increase of vascularity and thickening of the synovial membrane, 
with hypertrophy of the synovial villi. The subsynovial tissue thickens 
in cases of long standing along with the capsule, and the ligaments may 
become weakened and stretched. 

Intermittent synovitis, also called intermittent hydrops, is a well- 
recognized but rather infrequent affection, accompanied by no definite 
pathological changes, except perhaps a little laxity or thickening of the 
joint capsule. 

The knees are most often affected, but it has been recorded in other 
joints. No etiology has been formulated for the condition, the sexes 
being equally affected and the cases pretty evenly distributed through 
adult life. A case in a girl of nine has been reported. The character- 
istic of the affection is a non-inflammatory serous effusion occurring at 
more or less regular intervals, lasting a few days and disappearing spon- 
taneously, to return again and again. 

No satisfactory treatment has been formulated. 

Hip. 

Synovitis of the hip may occur in children or adults. It may follow 
any of the causes producing synovitis, but the common clinical ante- 
cedents are either trauma, rheumatism, or gonorrhoea. Its importance 
clinically is its resemblance in children to tuberculous hip disease. 

After a fall or during a rheumatic attack, pain, lameness, muscular 
spasm, flexion deformity, night cries, and muscular atrophy may be 
present for a while. These symptoms may disappear so rapidly that one 
is led to infer that synovitis has been present rather than tuberculosis 
or acute osteomyelitis. 

Twenty-one cases coming to the clinic of the Children's Hospital in 



OTHER AFFECTIONS OF BONES AND JOINTS. 229 

1897 and 1898, which presented at that time some or all of these symp- 
toms, were found in 1 901 -1902 to have entirely recovered. These 
were part of a series of ninety-five cases coming in those two years 
with a diagnosis of "hip disease" or "synovitis of the hip." The 
duration of symptoms in most of these cases had been less than two 
weeks at the time of examination. Atrophy was present in more than 
half, limitation of motion in all, lameness in all. Complete recovery oc- 
curred in these cases within one to four weeks in half of the cases. 1 In 
the other half the time of recovery was slower or could not be formulated. 

In children the diagnosis of synovitis of the hip-joint should be 
made only when recovery has occurred in a few weeks and has proved 
permanent. 

Treatment. — In children cases of synovitis of the hip-joint are to be 
treated in the same way as cases of tuberculous ostitis. 

Cases in adults, which are clearly to be recognized as synovitis, 
should be treated by rest to the joint, including, if necessary, either 
traction or protection by apparatus, followed by massage and stimula- 
tion of the local circulation. And every care should be taken to guard 
against using the unprotected limb too soon. 

Knee. 

Chronic Synovitis. — Chronic serous synovitis is at times the sequel 
of an acute or subacute attack. In such a case the acute symptoms 
gradually subside, leaving a joint somewhat thickened and containing 
fluid. If the condition persists the muscles become weakened and re- 
laxed, and lateral mobility may be present. The weakness of the mus- 
cles is itself a source of danger and may lead to further synovitis. 2 

At other times the chronic synovitis is the result of an irritation 
caused by loose bodies in the joint, displaced semilunar cartilages, hy- 
pertrophied synovial fringes, or lipoma arborescens. The continued 
strain on the knees induced by flat-foot is at times a cause of chronic 
synovitis. At other times it exists in connection with constitutional 
disease, such as syphilis and gonorrhoea, and the intermittent form 
must be mentioned. 

The treatment of the chronic form which has lasted over from the 
acute stage consists in fixation if heat, pain, and tenderness are present, 
along with compression by bandaging or strapping over the front of the 
joint with adhesive plaster. This fixation should be followed by mas- 
sage, hot-air baths, and douches to restore the circulation, along with 
the gradual resumption of use. 

] " Diagnosis of Hip Disease." Boston Med. and Surg. Journ.. August 14th, 
1902. 

- Hoffa : Berl. klin. Woch.. xli.,No. 1. — Lovett : Orth. Trans., xi.. 274. — Ten- 
ney : Annals of Surgery, July. 1904. 



230 



ORTHOPEDIC SURGERY. 



If the synovitis exists as the result of mechanical irritation, the irri- 
tating cause should be removed by operation. If flat-foot is present it 
should be corrected by plates. 

As a symptom of constitutional disease, treatment of the systemic 










:tT*;;. h 






\? 




m 




FIG. T95.— Right Knee-joint Bent. Sagittal section. Joint surface slightly separated, show- 
ing the infra-patellar fat pad, and the bursa under the patella tendon as well as the ex- 
tent of the joint synovial membrane. (Fick.) 



In resistant cases in which the diagnosis is not 



•condition is indicated 

clear, the joint should be opened, explored, and any irritating cause 

removed. 

Hypertrophy of the Synovial Villi. — This affection is a frequent 
cause of chronic synovitis. As the result of a synovitis, or in connec- 
tion with continued strain of the knees as in flat-foot, or in arthritis 



OTHER AFFECTIONS OF BONES AND JOINTS. 231 



deformans, hypertrophy of the synovial fringes occurs to an extent that 
makes of them foreign bodies. As such they are a source of continual 
irritation in the joint. The symptoms caused by them are pain, effu- 
sion varying at times, creaking, occasional catching, and some swelling 
of the joint membrane, with perhaps tenderness. 1 

The treatment at first should consist of fixation in the severer cases, 
and compression by plaster strapping over the front of the joint in the 

milder cases. Douches, massage, and 
the measures suited to the treatment of 
chronic synovitis should follow. Flat- 
foot should be corrected and the knee in 
general placed under the most favorable 
mechanical conditions possible. If this 
does not control the affection, the joint 
should be opened by an anterior incision 
on one or both sides of the patella, the 
interior of the joint inspected and ex- 
plored, and the projecting fringes re- 
moved with sharp scissors or a knife. 
The bleeding is generally slight. The 
joint may or may not be irrigated, ac- 
cording to the amount of bleeding ; the 
capsule should be stitched and the skin 
wound closed. The joint should be fixed 
for two or three weeks, after which pas- 
sive motion and graduated use are begun. 
Loose bodies in the joints are found 
most often in the knee, but occasionally 
in other articulations. The other names 
for the condition are loose cartilages, joint 
mice, floating or movable bodies in joints, 
etc. They can be divided into classes, 
according to their structure, as follows: 
fibromatous, lipomatous, chondromatous. 
They are formed in one of the following ways : 

(a) As the fibrinous residue of an exudation or blood clot. 

(b) As lipomata formed in the joint (see Lipoma of the knee-joint). 

(c) As broken-off osteophytes in arthritis deformans. 

(d) As hypertrophied or degenerated synovial tufts (see Hypertro- 
phy of synovial villi). 

(e) As marginal ecchondroses broken off, as in arthritis deformans 
(see Arthritis deformans). 

fainter and Erving: "Chronic Villous Arthritis." Am. Journ. of Orth. 
Surg., November, 1903. p. 109. 




Fig. 196. — Double Chronic Synovitis 
of Knees. 



232 



ORTHOPEDIC SURGERY. 



(f) As encapsulated foreign bodies, such as bullets and needles. 
(£■) As bits of cartilage or bone chipped off by traumatism or 




Fig. 197.— Right Knee-joint Flexed. Seen from the front. Front part of capsule with patella 
and quadriceps tendon are cut above joint and turned down. Between the condyles is seen 
the ligamentum mucosum, running from the sides of which are seen the alar ligaments. 
(Fick.) 



loosened by a degenerative process, the result of traumatism. 1 The 

1 Lefebre : These de Paris, 1891. — Ranzier : Rev. de Med., iSc)i,p. 30; Trans. 
Path. Soc. , 1896, xlvii., 177. — Whitman, Pediatrics, 1899, vii., Nos. 4 and 5 (with 



bibliography). — Painter and Ervin< 
No. 12. 



Boston Med. and Surg Journ., cxlviii. 



OTHER AFFECTIONS OF BONES AND JOINTS. 233 

fact that a fall may be the cause of this variety of loose body has been 
clearly proved. 

Loose bodies lie free in the joint or are attached by a slender pedi- 
cle. They may vary in size from that of a small pea to that of a horse 
chestnut, and are of all shapes. The smaller ones are most often 
shaped like melon seeds or are irregularly round, while the larger ones 
are more regularly round, concavo-convex, or spherical. Sometimes 
they are facetted and crowded together like the carpal bones, and again 
they are mulberry-shaped or pyriform. In one joint they may appear 
singly or in great numbers, and they may vary a great deal in size in 
the same joint. Over four hundred have been removed from one knee- 
joint. Next in frequency to the knee comes the elbow, and all of the 
larger joints are liable to contain these bodies. In external appearance 




Fig. 



-Lipoma from Knee-joint. (C. F. Painter.) 



they are whitish or yellowish, and vary from a soft consistence to a 
bony hardness. On section they show either a plain fibrous structure 
or a fibrous sheath enclosing a mass of fat. Again, the structure is of 
hyaline or fibro-cartilage, ordinarily without corpuscles, or of bone tissue, 
most often without Haversian canals. Frequently they present a com- 
bination of two of these forms. 

They are often found in connection with the changes known as 
arthritis deformans, and also in joint disease of various types. They 
may be found in connection with joint tuberculosis. In certain cases 
no cause can be assigned for their occurrence. 

In a majority of cases the first intimation to the patient that anything 
is wrong is that w T hile in the act of walking or stooping he is seized with 
such agonizing pain in the knee that he may fall to the ground, in many 
cases overcome with the sensation of faintness and sickening pain. At 
times this pain subsides almost immediately, and the patient is able to 



234 ORTHOPEDIC SURGERY. 

walk within a few minutes; but at other times the joint remains fixed 
in a position of more or less flexion, and any attempt to move it is at- 
tended with very severe suffering. In any event, such an occurrence is 
apt to be followed by an attack of synovitis lasting several days. Up 
to this time the joint may have been normal and given no trouble, or 
it may have been the seat of chronic inflammation. These attacks are 
likely to be repeated without any assignable cause. On manipulation 
of the joint with the fingers it is often possible to detect a loose body, 




FiG. 199.— Infrapatellar Pad Showing- Tabs. Left knee. (Tenney.) 

which shifts its position and is found first in one part of the joint and 
then in another. The most common spot where they can be detected 
externally is in the pouch over the external or internal condyle of the 
femur. They are felt as smooth, slippery bodies under the skin, which 
evade the fingers' grasp with surprising readiness. Occasionally they 
may be found over the tibia inside the ligamentum patellae, and when 
one of these substances has been found it is desirable to see if others 
are present in the joint. Sometimes it is impossible to detect any loose 
bodies from the outside, and the history of the case must be depended 
upon. 1 In some cases the attacks are of very frequent occurrence, 
1 Hoffa : Deut. med. Woch., March 3d and 10th, 1904. 



OTHER AFFECTIONS OF BONES AND JOINTS. 235 

while in others it is only at intervals of several weeks or months that 
the joint gives any trouble. 

With repetition of attacks the joint becomes more tolerant and the 
synovitis less severe. In cases in which arthritis deformans is present 
as the cause of the loose bodies, the history of the attacks is less typi- 
cal. The patient, however, experiences in a measure the same sudden 
catching of the joint, and movement of the affected knee is painful, re- 
stricted, and attended with a particularly distinct grating. 

Finding a movable body which can be slipped from place to place 
by manipulation establishes the diagnosis. 

In cases in which the loose body cannot be found, one must depend 
largely upon the history, making, however, frequent examinations un- 
der different conditions with the hope of ultimately detecting the for- 
eign body. 

The diagnosis between loose bodies, hypertrophied synovial fringes, 
and dislocation of the semilunar cartilage is often a difficult one to 
make, and dependence must be placed chiefly upon tenderness in a very 
small spot over the head of the tibia as establishing the probable occur- 
rence of dislocation of one of the semilunar cartilages. Diagnosis has 
frequently to be made by exploratory incision. 

Treatment. — In cases in which the loose body gives but little incon- 
venience and is kept from passing between the ends of the bone by a 
knee-cap, it may not be advisable to undertake operative treatment. 
In other cases, especially in arthritis deformans, the joint may have 
become so much impaired by the disease that even if a foreign body 
were removed little would be gained. In the great majority of cases, 
however, inasmuch as the disease occurs in otherwise healthy persons, 
mostly young adults, any operation which does not entail serious risk 
is advisable. 

The operation is performed as follows : 

The loose body having been found, a needle is passed through it 
from the outside to steady it, and it is then cut down upon by careful 
dissection until it is exposed and removed. After the removal of the 
body originally detected, the joint should be carefully examined to see 
if others are present. There is, of course, a slight tendency to the re- 
formation of these bodies after one or more have been removed. 

Lipoma. — Fatty growths may form in the joints, acting as foreign 
bodies and causing chronic or recurrent attacks of acute synovitis. 
Although other joints are not exempt, the common seat of occurrence 
is in the knee. 

The occurrence of such growths in the knee-joint has been described 
in the form of the lipoma solitarium of Konig and as the lipoma arbo- 
rescens of Miiller. 

The lipomata vary in size, being sometimes as large as an egg, and 



236 ORTHOPEDIC SURGERY. 

are attached to the synovial membrane by a pedicle. In shape they 
may be regular or irregular and are studded with small tabs of fatlike 
tissue. They are frequently the result of trauma, and are formed either 
by the intrusion into the joint of the perisynovial fat tissue through a 
slit in the synovial membrane, or they are the result of inflammatory 
hyperplasia of the articular adipose tissue l or of the synovial villi. 2 
Once formed, such a mass acts as a foreign body, and clinically a swollen 
joint is found with little or no effusion. The function is imperfect and 
pain may be present, and the joint is liable to lock in partial extension. 
The swelling is chiefly noted at the side of the patella tendon. The 



X 




Fig. 200.— Tibial Joint Surfaces of Knee Seen from Above, Showing Semilunar Cartilages. 

(Fick.) 

diagnosis from hypertrophied villi and similar conditions is difficult and 
often to be made only on exploration. The treatment consists in the 
removal of the mass. 

Dislocation of the Semilunar Cartilages 3 (Hey's Internal Derange- 
ment). — The affection is nearly always traumatic in origin and consists 
in the tearing loose from its tibial attachment of the internal or exter- 
nal semilunar cartilage. The internal is the one most frequently dis- 
placed. This is probably for two reasons : first, because it has less mo- 

1 Hoffa: Journ. Am. Med. Assn., September 17th, 1904, p. 795. 

-Painter and Erving : Boston Med. and Surg. Journ., March 19th, 1903 (with 
literature). — Stieda : Beitr. z. klin. Chir., xvi., 285, 1896. 

8 Hey : " Practical Observations in Surgery," 1803. — W. Bromfield : " Chirurgi- 
cal Observations/' 4 cases, vol. ii., 1753. — Tenney : Annals of Surgery, July, 1904 
(with bibliography). — Ferd : Archiv f. Orth., i., 2, 1903. — Bovin : Abst. Am. Journ. 
Orth. Surgery, vol. i., p. 224. 



OTHER AFFECTIONS OF BONES AND JOINTS. 237 

bility on the tibia than the external ; and secondly, the motion most 
likely to displace it forcibly is outward rotation of the tibia on the femur, 
or, what has the same effect, inward rotation of the femur on the tibia. 
It is probable that some looseness of the ligaments of the knee is asso- 
ciated with the injury to the cartilage. It must be remembered that 
the knee is not a strictly hinge joint, but that in extension the leg ro- 
tates outward upon the thigh, especially at the end of extension, when 
a quick outward rotation of the tibia occurs, locking the leg in complete 
extension. 

A sudden wrench or twist in slight flexion is the accident most 
often causing displacement of these cartilages. 

The symptoms are in a measure similar to those caused by loose 
bodies, and similar to, but generally rather more than, those caused by 
hypertrophied synovial fringes and the like. The patient, by some vio- 




FlG. 2oi.^Three Right Internal Semilunar Cartilages Showing- Fracture Opposite Internal 
Lateral Ligament, Upper Surface. (Tenney.) 

lent muscular effort or by some sudden twist, as in kicking football or 
falling from a horse or carriage, wrenches the knee and finds it impos- 
sible to extend it fully, and walks with it bent in the way described, 
suffering much pain. This sudden locking of the joint, so far as exten- 
sion is concerned, is almost the only characteristic symptom of internal 
derangement ; but generally on examination one finds a protrusion of 
one of the semilunar cartilages. This establishes the diagnosis, and a 
sharp attack of synovitis of course follows such a severe injury to the 
joint. 

In some instances much tenderness can be found over the inner 
tuberosity of the tibia where none is present over the outer tuberosity. 

The most marked cases happen after some serious wrench to the 
joint. Nevertheless, cases occur in which the cartilage is perhaps only 
relaxed, and in these a much less painful locking of the joint arises. 
The affection is masked in many patients by the severity of the acute 



2 3 8 



ORTHOPEDIC SURGERY. 



synovitis which follows the injury, and the true character of the acci- 
dent may not be learned for a long time afterward unless its history is 
most carefully inquired into, the condition in this case passing for a 
simple traumatic synovitis. One occurrence of the accident predisposes 
to subsequent attacks. ■ Lateral mobility of the knee is likely to exist 
in cases of long standing. 

This dislocation affects, for the most part, persons between twenty 
and fifty years of age; men are much more frequently affected than 
women ; it rarely occurs in children. 

Patients who are liable to the displacement soon learn the manipu- 
lation of reduction themselves. The knee should be bent to its fullest 

extent; the tibia should then be 
drawn away from the femur as 
far as possible, to separate the 
joint surfaces, at the same time 
rotating the tibia inward or out- 
ward as the internal or external 
cartilage is displaced, and then 
the leg should be extended quickly 
but not forcibly to its fullest ex- 
tent, while the surgeon manipu- 
lates with the thumb the situation 
of the semilunar cartilages, es- 
pecially if any undue prominence 
should be felt. An anaesthetic 
is very often necessary or ad- 
visable. The reduction in ex- 
ceptional instances cannot be 
effected, but commonly, and spe- 
cially with the use of an anaesthet- 
ic, reduction takes place easily and 
a distinct click is heard in many 
cases. 

The cartilage may after reduction become united to the tibia 
by its former attachments or it may remain loose, to cause further 
attacks. It may be simply torn from its tibial attachments and re- 
main attached as before at its two ends, or it may also be torn across 
in the middle, and the free end may cause trouble by acting prac- 
tically as a loose body. Finally, entire detachment of the torn 
piece may occur, in which case it becomes a loose body of the car- 
tilaginous class. 

The injuries found in 128 operations for the relief of injured semi- 
lunar cartilages are as follows : ' 

1 Tenney : Loc. cit. 




FlG. 202.— Semilunar Cartilage of Right Knee 
Showing Effects of Long-Continued Fric- 
tion. (Tenne}'.) 



OTHER AFFECTIONS OF BONES AND JOINTS. 239 

Internal. External. 

Torn from or near anterior attachment 23 3 

Transverse tear at or near lateral ligament 38 

Longitudinal split, incomplete 16 1 

Longitudinal split, complete 8 

Turned into intercondylar notch 3 1 

Loose 23 3 

Cystic ■■ . 1 1 

Ossified 1 

Doubtful , 1 5 

113 15 

The treatment after the original accident is reduction of the dis- 
placed cartilage, followed by the usual treatment for the acute synovitis 
which ensues. 

If the attacks recur, especially on slight cause, it is likely that the 
cartilage has been permanently loosened from its attachments and will 
be in all probability a source of further trouble. The treatment may 
under these circumstances be mechanical or operative. 

1. Mechanical Treatment. — Although the use of knee-caps with 
pads beside the patella, elastic bandages, etc., may prove of use in pre- 
venting in part future attacks, they can hardly be recommended as a 
form of treatment on account of the great inconvenience attending 
their use, and the fact that they are to be regarded as palliative rather 
than curative. 

The mechanical treatment advocated by Shaffer a for this condition 
is as follows : The treatment is the application of an apparatus to the 
thigh, leg, and foot, allowing only the hinge motion, thus preventing, at 
least in large measure, the slight rotation at the knee occurring in ex- 
tension of the leg. The apparatus also is arranged by a stop-joint at 
the knee to prevent complete extension of the knee. It consists of an 
outside upright attached to the boot and reaching to the upper part of 
the thigh, and an inside upright reaching from the upper thigh to the 
upper part of the calf, and a pad is placed over the inner aspect of the 
knee. The object of this treatment is, by preventing harmful motions 
and positions for some months, to produce a reunion of the cartilage to 
its proper attachments and a return of the ligamentum patellae to its 
proper length. 

2. Operative treatment is, as a rule, surer, quicker, and more accept- 
able to the patient. The joint is opened inside or outside of the liga- 
mentum patellae, according to the cartilage displaced, by a vertical in- 
cision. The joint should be explored and the loose part of the cartilage 
removed. The joint capsule should be stitched and the wound closed. 
Fixation should follow for two or three weeks, after which passive mo- 
tion and massage should be commenced. 

] Annals of Surgery, October, 1898. 



240 ORTHOPEDIC SURGERY. 

Cysts of the Knee-joint. — Cystic swellings in connection with the 
larger joints, especially the knee-joint, occur at times. 1 These swell- 
ings are found from time to time in the neighborhood of the knee-joint, 
generally in the popliteal space. At first there is nothing to suggest 
their connection with the joint in any way, for the cyst may be at a 
considerable distance from the joint. There may be no fluctuation to 
be obtained between the joint and the cyst, nor can the fluid from the 
cyst be pressed into the joint; yet such cysts, as a rule, connect with 
the joint. 2 

The affection is found most often in early and middle adult life. 
The diagnosis from bursitis is often difficult. Extirpation of the sac is 
the only treatment likely to be of use. 

Trigger Knee. — The so-called trigger knee, described also as genou 
a ressort or schnellendes Knie, is characterized clinically by a disturb- 
ance in extension of the leg. Extension is normal until about 160 is 
reached, is then completed with a snap and forcible jerk, during which 
there is also outward rotation of the tibia. It is not connected with 
any disease of the knee-joint nor any obvious abnormality save loose- 
ness of the ligaments. The cause is evidently a disturbance of the 
movement of the semilunar cartilages, particularly the external, which 
is caught between the joint surfaces and suddenly freed, producing the 
jerk described. The prognosis in children is good, depending upon 
tightening of the ligamentous structures with or without treatment. 
Mechanical treatment is apparently not necessary, at least in children. 3 

Irritability Secondary to Malpositions of the Foot.— Certain malpo- 
sitions of the foot may result in pain, irritation, and synovitis of the 
knee-joint, when the knee is affected only secondarily. Such disturb- 
ances occur in flat-foot, pronated foot, and shortening of the gastrocne- 
mius muscle. The consideration of this subject will be taken up later. 

Ankle-Joint. 

Chronic Synovitis. — Chronic synovitis is most likely to be the out- 
come of the acute condition which for some reason has not properly 
recovered. In cases of long standing the circulation and innervation 
of the foot and leg become impaired, and swelling and congestion occur 
in connection with pain, tenderness, and impaired use. Malpositions 
of the foot may occur, the most common being a limitation of dorsal 
flexion. In simple chronic synovitis motion is generally but little lim- 
ited and not very painful, or but slightly so, so that weakness, swelling, 

1 St. Bartholomew's Hospital Reports, vol. xiii., p. 245 ; vol. xxi., p. 177. 

2 Cent. f. Chir., 1898, p. 585. 

"■Trans. Am. Orth. Assn., vol. x., p. 40.— Thiem: Monatsch. f. Unfallheilk., 
1896, p. 182.— Rolen: Ibid., 1898, 377.— Nasse: Deutsche Chir., Lief. 66, Heft 1, 
p. 299. — Cotton: Journal Boston Society Medical Sciences, May, 1899. 



OTHER AFFECTIONS OF BONES AND JOINTS. 241 

and stiffness of the joint with occasional pain are the only symptoms 
complained of. 

Tenosynovitis, which ma)' exist alone or in connection with chronic 
synovitis, gives rise to swelling around the tendons; there may be 
some puffiness of the skin, heat, hyperesthesia, and pain on certain 
movements of the foot ; but extreme change in contour of the ankle is 
not present, and the pain is chiefly that of apprehension. In manipulat- 
ing the foot a creaking at the painful spot may be felt, and this spot 
itself is sharply localized, and as a rule is not over the joint, but in the 
course of the tendons. 

Treatment . — If heat, pain, and irritability are present, protection 
from weight-bearing by the use of crutches is indicated, and in the se- 
verer cases fixation of the joint by a plaster-of-Paris bandage is desir- 
able. Compression is of value, and this can be obtained, with some 
degree of fixation, by surrounding the front and sides of the ankle-joint 
with a series of overlapping straps of adhesive plaster, each of which 
starts under the sole of the foot, passes obliquely over the top of the 
tarsus, and up behind the ankle. Applied under moderate tension, this 
dressing is an efficient and comfortable support. 

Following this stage of the inflammation, the gradual resumption of 
use is indicated, along with measures to stimulate the general circula- 
tion, such as douches, massage, vibratory massage, hot-air baths, and 
Bier's congestive treatment. 

If slight valgus position exists incidental to weakened muscles, it 
should be treated. If limitation of dorsal flexibility of the foot is pres- 
ent, it should be corrected by stretching the gastrocnemius muscle. 

Shoulder-Joint. 

Chronic synovitis of the shoulder is an affection existing either 
as a sequel of an acute attack, the result of some injury, or as a 
slow, persistent process, beginning with slight symptoms easily disre- 
garded. 

The earliest symptom to attract notice is stiffness, observed partic- 
ularly in forced movements, as in placing the hand on the head, etc. 
Pain is a variable symptom. 

A slight fulness about the joint may be detected at this time, the 
humero-pectoral groove being indistinct, and the depression below the 
acromion obliterated. Although an increase of surface temperature 
may often be detected, its absence is of little importance, the joint be- 
ing so thoroughly covered. As the disease progresses, the case pre- 
sents an exaggeration of the early symptoms ; motion becomes more 
restricted, swelling increases as effusion takes place, the shoulder appear- 
ing broader, and elevations may replace the natural depressions. Atro- 
16 



242 ORTHOPEDIC SURGERY. 

phy of the deltoid and scapular muscles gradually occurs. Pain is a 
symptom of varying severity. In general, the tendency is toward reso- 
lution with more or less impairment of joint motion. 

Tenosynovitis may exist and simulate closely chronic synovitis of 
the shoulder. 

Periarthritis of the Shoulder. — Periarthritis of the shoulder-joint has 
been described ' as a condition of stiffness not infrequently seen after 
comparatively slight injuries. Pain accompanies motion beyond a cer- 
tain limit. Atrophy of the muscles is present, and at times there is 
some spontaneous pain. The arm may become of comparatively little 
use. The diagnosis of periarthritis is not based on pathological evi- 
dence.' 2 In most cases it is of traumatic origin. 

Treatment. — In synovitis of the shoulder-joint with any active in- 
flammation, the indication is simply for rest and fixation. These are 
readily secured by means of a sling and a bandage securing the arm to 
the side. It is important to mention that in chronic synovitis of the 
shoulder the weight of the arm dragging upon the joint structures may 
be a factor in keeping up the pain and irritation. Consequently in the 
shoulder the use of a supporting sling is necessary in these cases. 
Compression will be needed if there are swelling and effusion. Trac- 
tion may be required in the severest cases. Fixation should not be 
continued longer than there is subacute inflammation, and can be grad- 
ually discontinued ; first discarding the bandage and retaining the sling, 
which can be discontinued later. So long as muscular irritability ex- 
ists, rest is indicated. In these cases an increased arc of motion and 
diminished sensitiveness will usually follow a few days' rest of the joint, 
and permanent ankylosis is rendered less likely by the application of 
timely immobilization. 

Fixation should be followed by measures to restore motion and to 
stimulate the circulation. 

The question of the use of forcible passive motion in the convales- 
cent stage does not differ from the same question in other joints. If 
the stiffness is due to adhesions, manipulation under an anaesthetic, 
followed by massage, etc., may be of value ; but in the majority of 
light cases gradual passive exercises will suffice. Gentle, graduated, 
passive motion carried to the verge of being painful, with the use of 
electricity, is of great advantage in many cases of shoulders stiffened 
from a slight degree of chronic joint inflammation. If the stiffness 
above alluded to is the result of the fixation due to muscular spasm, 
forcible passive motion will be of no use, as the reflex spasm will reap- 
pear after the effect of the anaesthetic has passed away, as long as the 
disease of the joint remains. 

1 Duplay : Arch. Gen. de Med.. Paris. 1S72 

-Jones and Allison: N. Y. and Phila. Med. Journal. 1904. 



OTHER AFFECTIONS OF BONES AND JOINTS. 243 

The treatment of tenosynovitis and periarthritis does not differ 
essentially from that just described. 

Obstetrical paralysis of the shoulder will be considered in a later 
chapter. 

Elbow-Joint. 

Chronic synovitis may appear in this, as in other joints, from the 
usual exciting causes, and presents the same characteristics. What is 
popularly spoken of as a " tennis elbozu " is a chronic synovitis and irrita- 
bility, in which injury to the ligaments, especially to the internal lateral 
ligament, is a marked feature. It results from the strain of constant 
tennis-playing or some similar overuse of the elbow, and its treatment 
does not differ from that of a similar condition in other joints. 

Wrist. 

Chronic synovitis ma)- occur under the same conditions existing in 
other joints. Tenosynovitis is characterized by pain on the motion of 
certain fingers, with, perhaps, a sensation of rubbing or creaking in the 
affected tendons. Tender points are present in the course of these 
tendons. In the superficial tendons of the wrist, some distention of the 
synovial tendinous sheath can be seen. 

The synovitis of other joints does not require especial mention. 

BURSITIS. 

Hip. — Inflammation of the bursae about the hip-joint must be recog- 
nized as a condition likely to give rise to symptoms possibly resembling 
hip disease. 1 This inflammation is most often traumatic, but may be 
tuberculous. Suppuration and the formation of fistulas may occur. 
According to the location of the inflammation the symptoms will differ. 

The chief bursae about the hip are as follows : The subiliac bursae 
under the ilio-psoas tendon as it leaves the pelvis ; the bursa under the 
insertion of the tendon of the ilio-psoas. About the trochanter major 
there are several : one between the fascia lata and the skin ; a less con- 
stant one between the fascia lata and the trochanter; one under the 
gluteus medius ; one under the tendon of the gluteus minimus ; one 
between the obturator externus and the gemelli; one for the pyri- 
formis ; one for the obturator internus. A bursa farther removed from 
the hip-joint, but one likely to be affected, is one between the gluteus 
maxim us and the tuberosity of the ischium. This affection may be 
mistaken for hip disease, as there are limitation of motion and limp, and, 
in the severest cases, suppuration. The diagnosis at times can be es- 

1 Deutsch. Zeit. f. Chir.. December. 1898. — Brackett : Trans. Am. Orth. Assn., 
1896. — Lippert : Beitr. z. klin. Chir.. xl., 503. 



244 



ORTHOPEDIC SURGERY, 



tablished only after incision. The treatment consists of the temporary 
use of crutches and incision in the severer cases. 

Bursitis of the Knee. — The various bursae about the knee may be- 
come inflamed and give rise to disability, often of an obscure nature. 

Housemaid's Knee. — The most common seat of this affection is 
in the prepatellar bursa which lies over the patella and part of the liga- 
mentum patellae. This is not, as a rule, one well-defined sac, but con- 
sists of three layers of bursae 
more or less well marked 
and generally in communi- 
cation with each other and 
at times with the knee- 
joint. 1 

This affection is found 
chiefly in persons whose 
occupation leads them to 
spend much time in kneel- 
ing. The acute affection is 
brought about by over-use 
of the knee, and is charac- 
terized by slight swelling, 
sensitiveness on pressure, 
and discomfort in flexing 
the knee, which is localized 
at the site of the bursa. 
Palpation shows a more or 
less distinct swelling, which 
lies over the patella and 
which is rendered more 
tense by the flexion of the 
joint. In the acute stage it is 
likely to be mistaken for sy- 
novitis of the knee-joint, es- 
pecially as the inflammation, 
if neglected, tends to spread and the swelling may become more diffuse 
and burrow around the joint; although the chronic enlargement of the 
bursa is sometimes primary, more often it is the outcome of a series of 
acute attacks. Fluctuation is clearly present, and the swelling is more 
sharply localized to the region in front of the patella than in synovitis. 
In the chronic stage of the affection, heat, sensitiveness, and discomfort 
are ordinarily absent, except a slight feeling of stiffness in complete 
flexion of the leg. 

For diagnosis, one must depend upon the facts that the swelling is 
1 Bize : Journ. d'Anat. et de Phys., Paris, xxxii., 1896, p. 85. 




FIG. 203. — Prepatellar Bursitis. 



OTHER AFFECTIONS OF BONES AND JOINTS. 245 

entirely in front of the patella, that the patella does not float, that the 
joint is not affected, and that the occupation of the patient in someway 
has produced continual slight injuries of this region. Although the 
acute affection shows a tendency toward recovery under rest, the 
chronic affection does not have this tendency and is likely to continue 
unabated. 

Suppuration occurs in both acute and chronic varieties in a certain 
proportion of cases. The inflammation of the bursa occasionally occurs 
in connection with gout, rheumatism, or syphilis. 

Treatment. — The acute affection, unless too far advanced, ordinarily 
yields readily when the limb is placed in the extended position upon a 
ham splint and the constant irritation of walking is avoided. The appli- 
cation of pressure is of much assistance in allaying the inflammation ; J 
a few days or weeks in the milder cases will ordinarily reduce the in- 
flammation. In old cases this treatment has little or no effect. If, 
however, the bursitis has reached the stage of suppuration, incision 
affords the only hope of relief. 

In chronic bursitis the most satisfactory treatment is to lay the entire 
bursa open by a crucial incision and dissect out the tough fibrous sac. 

Bursitis of the Deep Prepatellar Bursa. — The affection of 
this bursa presents certain characteristic symptoms often difficult to 
differentiate from those of synovitis. This bursa lies beneath the liga- 
mentum patellae next to the tibia. 2 

The inflammation of this bursa is described under various names, 
one of them being pseudarthrose du genou? 

The peculiar symptoms of this affection are pain in complete exten- 
sion of the leg, referred to the tubercle of the tibia ; pain and tender- 
ness, referred to the patella tendon ; apparent enlargement of the tuber- 
cle of the tibia, and bulging at the sides of the ligamentum patellae. 
The affection 4 may be mistaken for inflammation of the superficial 
pretibial bursa or for the inflammation of abnormal bursae in this 
neighborhood. Careful examination will usually differentiate it from 
synovitis of the knee-joint. Tuberculosis of this bursa may occur. 

The treatment does not differ from that of housemaid's knee except 
that bursitis of the deep pretibial bursa is more obstinate. 

The inflammation of other bursae about the knee-joint presents no 
peculiar symptoms, and the existence of the affection is made evident 
by the presence of a fluctuating swelling at the site of a bursa. 

1 Hoffmann : Am. Journ. of Orth. Surgery, vol. ii., 2. 

- Lovett : Boston City Hosp. Reports, 8th series, p. 345. 

■' Dubreuil : Annales d'Orth., Paris, September, 1890. — " Traite de Path, ext." 
(Follin), iii., 19. — Pitha and Billroth: "Chirurgie," iv., 1, Heft 2, p. 242. 

4 Osgood: Boston Med. and Surg. Journ., January 29th, 1903 (with literature). 
—Lovett: Phila. Med. Journ., January 6th, 1900. 



246 ORTHOPEDIC SURGERY. 

Bursitis ' of the Shoulder. — Although this affection may simulate 
synovitis, the limitation of motion induced by it is only in certain direc- 
tions, and tenderness and swelling are chiefly confined to the affected 
structures. The bursae most frequently affected are those of the sub- 
scapular, the deltoid, and the coracoid regions. The disease is generally 
tuberculous. 

HABITUAL OR RECURRENT DISLOCATIONS. 

Patella. — Dislocation of the patella or slipping patella is likely to 
occur either spontaneously or for very slight cause in certain young 
girls with lax muscular fibre and a feeble development, and boys are 
only exceptionally attacked. 2 

In consequence of some slight twist of the leg, as in dancing, rising 
from a chair, going upstairs, or some similar motion, an excruciating 
pain is felt in the knee, and the person either falls in consequence of 
faintness or finds herself unable to use the leg. Very often the patient 
herself hears a cracking sound when the dislocation occurs. The patella 
is found almost always dislocated outwardly, sometimes twisted so that 
its lateral edge rests against the front of the femur (vertical luxation of 
Malgaigne). The reduction of the dislocation is very simple and is very 
soon learned by the patients themselves. The leg is fully extended and 
the patella gently pressed back into place until it assumes its proper 
place with a click, or often it slips back of its own accord when the leg 
is straightened. An attack of synovitis follows, as in the case of loose 
bodies, but the joint soon acquires a tolerance so that each succeeding 
attack of synovitis becomes less. 

The cause of the affection seems to be, in most cases, the lack of 
tonicity in the extensor muscles of the thigh, or the elongation of the 
ligamentum patellae, but very commonly the former. 

After many attacks of dislocation the patients complain of a certain 
sense of insecurity in walking, which in severe cases may amount to a 
distressing disability, limiting the patient's ability to walk or engage in 
active occupation. 

MecJianical Treatment. — If an elastic knee-cap is split in front and 
furnished with lacings or straps, and if felt pads are sewed upon the sides 
of the cap at such places as would exert pressure upon the sides of the 
patella, an arrangement is furnished which, when properly adjusted, 
will give a serviceable support in lighter cases, allowing motion at the 
knee. 

The following steel appliance will be found of service: It consists 
of two uprights, hinged at the knee, extending from the middle of the 
calf to the middle of the thigh on each side of the limb, and connected 

1 Blauvelt : Beitr. z. klin. Chir. ,'xxii. — Ehrhardt: Arch. f. klin. Chir., 1900, xl. 
-Bade: Zeit. f. orth. Chir., xi., 3. 



OTHER AFFECTIONS OF BONES AND JOINTS. 247 

with cross-pieces above and below. To these are attached at the level 
of the middle of the patella semilunar plates, which are of such a shape 
and arc bent in such a way as to press upon the sides of the patella. 
They arc covered with padding and leather. If leather straps pass diag- 
onally from the uprights to buttons upon the top and bottom of these 
plates, an adequate amount of side pressure will be secured. Two 
straps from underneath the knee prevent the apparatus from falling 
forward, and the straps mentioned prevent the apparatus from slipping 
backward. It is essential that this appliance should not remain in a 




Fig. 204.— Dislocation of Patella. 



bent position, as the pressure at the sides of the patella would in that 
case be diminished. To prevent this a spring is furnished, connecting 
the upper portion of the upright with the lower portion, with sufficient 
strength to force the appliance into a straight position, but allowing 
bending of the knee by muscular effort. 

Some such retentive apparatus, along with the use of massage and 
electricity, may effect a cure, especially in rapidly growing girls. 

Operative Treatment . — In resistant cases, or those unable to follow 
out proper mechanical treatment, operation will be required. 1 

This consists in the removal of an elliptical piece of the front of the 
'Bade: Zeit. f. Orth. Chir.. xi.. 3, 451 (with bibliography). 



248 ORTHOPEDIC SURGERY. 

capsule of the joint internal to the extensor tendon and a stitching to- 
gether of the edges of the opening, thereby tightening the inner part of 
the capsule. 1 

In resistant cases a vertical incision outside of the patellar tendon 
must also be made to allow the patella to be pulled into place by the 
tightening of the capsule on the inner side. 

The tubercle of the tibia may be transplanted 2 farther in on the tibia, 
or the patella tendon may be split longitudinally and the inner half car- 
ried under the outer and attached to the tibia outside of the tubercle. 3 

Habitual or recurrent dislocation of the shoulder becomes at times 
an affection requiring orthopedic treatment. 

The causes of the condition may be formulated as follows: 4 I. Lax- 
ity of the capsule of the joint. 2. Partial fracture of the head of the 
humerus. 3. Partial fracture of the glenoid cavity. 4. Tearing away 
of muscular insertions and rupture of tendons. 5. Abnormality in the 
shape of the head of the humerus not demonstrably due to fracture. 

It would seem as if in certain instances the cause of the recurrence 
of the dislocation was insufficient immobilization of the arm after a pri- 
mary dislocation. 

The atrophy of certain muscles seems to be characteristic in these 
cases in a series observed by one of the writers. 5 These are the cora- 
cobrachialis, triceps, deltoid, especially the posterior part, supra- and 
infraspinatus, rhomboids, levator anguli scapulae, and latissimus dorsi. 
Limitation of motion is not so much due to pain or to fear of displace- 
ment as apparently to some lesion in the joint mechanism. It should 
be noted that a large proportion of epileptics are found in all reported 
cases. Reduction is as a rule easy, and inflammatory reaction in the 
joint is notably slight or even wholly absent after reduction. 

Prognosis.— -In a shoulder-joint in which a dislocation has once or 
twice occurred from insufficient cause, it is not likely that the liability 
will become less frequent as time advances if no treatment is under- 
taken. As a rule, the dislocations will occur with greater frequency 
and from slighter causes as time progresses. 

Treatment. — The methods of treatment are : 

By apparatus ; by massage and exercises alone ; by temporary fixa- 
tion and massage; by operation. 

The use of apparatus confining the arm to the side is to be cori- 

1 N. Y. Med. Record, April 20th, 1895.— Trans. Am. Orth. Assn., vol. viii., p. 
227. — Ibid., vol. viii.. p. 237. 

2 Annals of Surg., 1899. 

3 Goldthwaite : Am. Journ. Orth. Surgery, vol. i., No. 3. 

4 Stimson : " Dislocations," p. 265, quoting also Gurlt, " Path. Anat. der Ge- 
lenkkrankheiten," p. 250. — Cushing : Med.-Chir. Trans., 1837, p. 336. 
5 Burrelland Lovett : Am. Jour. Med. Sciences, August, 1897. 



OTHER AFFECTIONS OF BONES AND JOINTS. 249 

demned. It weakens the muscles by causing their disuse. It is un- 
comfortable and partially disabling, and its use can be considered justi- 
fiable only temporarily or under exceptional conditions. 

An apparatus used by one of the writers seems as little objection- 
able as any. It consists of a leather shoulder cap embracing the arm, 
strengthened by two steel strips, one horizontal strip running from 
before backward and fitting the outer contour of the shoulder. The 
other, a longitudinal strip, runs from the base of the neck to the middle 
of the outside of the arm. There is a joint connecting the two steel 
strips opposite the shoulder, allowing antero-posterior motion in the 
shoulder. The shoulder cap is fastened in place by a chest band; the 
apparatus prevents abduction of the arm to any degree likely to pro- 
duce dislocation. 

Fixation for some time is called for when a second dislocation has oc- 
curred from slight cause. The arm is lifted by applying a sling, which 
supports the forearm and point of the elbow. The arm is held to the 
side by a swathe, thus preventing all motions of the joint. This re- 
moves as much weight as possible from the joint capsule. 

Such cases have been operated upon successfully by reefing the an- 
terior part of the capsule of the joint through an anterior incision. 1 

Symphysis Pubis.— Relaxation of the joint in the symphysis pubis 
occurs at times during pregnancy, so that walking becomes difficult or 
impossible. After delivery the abnormal condition may disappear or 
may persist as a source of disability. It is best treated by a leather or 
plaster jacket fitting tightly over the sacrum and ilia, along with as 
much limitation of walking as may be necessary. 

TUMORS OF THE BONES AND JOINTS. 

Primary tumors of bone belong to the group of connective-tissue 
tumors. The periosteum and bone marrow form the matrix for their 
development. These tumors correspond to the various types of connec- 
tive tissue, fibrous, mucoid, cartilaginous, and osseous. Among pri- 
mary tumors are to be classed sarcomata. Secondary tumors of any 
kind may occur, among the latter being carcinoma. Angioma, haema- 
toma, echinococcus cyst, and aneurism must be mentioned as other 
possibilities. 

Exostoses. — Apart from the changes of arthritis deformans, there 
sometimes occur exostoses about the articular ends of the bones, which 
are very rarely large enough to impede the motion of the joints ; at 
other times they are troublesome by involving tendons in their growth. 

1 Cent. f. Chir., 1883, p. 28; Beilage z. Cent. f. Chir., 1882, p. 73, and 1886, p. 
90; Deutsch. Zeit. fur Chir., 1880, xiii., p. 167.— -Pitha and Billroth, ii., p. 652. — 
"Aseptic and Antiseptic Surgery," p. 8. — Bull, de l'Acad. de Med., 1894, p. 334. — 
Burrell and Lovett : Am. Jour. Med. Sciences, August, 1897. 



ORTHOPEDIC SURGERY 




Cartilaginous exostoses in the neighborhood of the joints have occa- 
sionally a capsule overlying the layer of cartilage corresponding in 

structure to synovial membrane. This con- 
dition is spoken of as a bursate exostosis. 

Chondromata. grow most frequently from 
the bones of the hand. They are often mul- 
tiple, occur most often in children and young 
adults, and may be congenital. Myxomata 
and lipomata are rare in the bones. 

Sarcomata originate in the marrow or 
periosteum. If they contain bony tissue they 
are spoken of as osteosarcomata. Joint sar- 
comata affect chiefly young subjects from 
fifteen to twenty-five years old, and the 
joints commonly affected are the knee, shoul- 
der, and wrist. Central sarcomata are more 
likely to invade joints than are the periosteal 
growths. Males are slightly more liable than 
females' to be affected. 

Carcinomata of bone 
may occur secondarily 
from extension or me- 
tastasis. They occur in 
circumscribed nodes or 
as a diffuse infiltration. 
The latter form is usually 
accompanied by prolifer- 
ation of the periosteum 
and absorption of the 
substance of the bone. 
This is at times re- 
placed by soft new bone, 
and a condition may be 
present resembling lo- 
cally osteomalacia and 
known as carcinomatous 
osteomalacia. 

With this form, as 
with primary new growths, spontaneous fracture may occur. 




Fig. 205.— Tumor of Femur Involving Knee. 



Malignant Disease of the Spine. 



Sarcoma and carcinoma of the vertebral column are occasionally 
met. Carcinoma has been noted following similar disease of the breast 



OTHER AFFECTIONS OF BONES AND JOINTS. 251 

and testicle, and less frequently of the stomach. The occurrence may 
be from direct extension or from general infection. 

The disease usually begins as an infiltration of the spongy tissue of 
the vertebral bodies, which is gradually replaced by the malignant 
growth. There may be but little change in the appearance of the bod- 
ies, but these will be found converted into a soft, friable mass. De- 
struction of the bone substance with deformity may occur. 

The most frequent site of malignant disease is in the lumbar region, 
and the next commonest location is in the dorsal vertebrae. 

The disease may pursue an insidious course, and not be suspected 
until found at the autopsy. This, however, is rare, and a serious affec- 



m^'"^F*BL 


r~-T- — --— — 


P 




■ Jm 


bbS^^^b 1 


■ 


i^-wk^r 1 




^smmWmmm^-- 'Jjl 


% 


^•^^si 


!*: ^ 


r—^Vm 


*^>^ 


1 


■2T«, 


1 H»l 



Fig. 206. — Sarcoma of Spine. 

tion is usually evident, even though no diagnosis is made. The symp- 
toms are similar to those of Pott's disease, pain being very prominent, 
with frequently paralysis. Both are the result of the encroachment of 
the growth on the spinal nerves and cord. The location of the pain 
will depend on the site of the diseased vertebrae, and it is usually in- 
creased by pressure and motion, and it extends in the arms, trunk, or 
legs. 1 The paralysis usually follows a disturbance in sensation, and is 
due to compression from extension of the disease or from involvement 
of the meninges. It maybe partial or complete, and as a rule does not 
occur suddenly. Tenderness over the spine is an uncertain sign, and 
probably has no diagnostic importance. When deformity occurs it will 
1 Edes : Bost. Med. and Surg". Jour.. June 17th. 1886. 559. 



252 ORTHOPEDIC SURGERY. 

be found to present a more rounded prominence than is usually seen in 
Pott's disease. Hemorrhage from the bowels or hematuria has been 
observed. 

When following malignant disease elsewhere, which can be recog- 
nized, the diagnosis should present no special difficulty, but in other 
instances it is usually hard or even impossible. It should be distin- 
guished from aneurism of the aorta, cervical pachymeningitis, and Pott's 
disease. 

The prognosis needs no comment ; a fatal end is only a matter of 
time. 

Malignant Disease of the Hip. 

The variety of tumor which most often affects the head of the fe- 
mur in young children is a round-cell sarcoma of the periosteum. But 
the epiphysis is rarely the seat of the tumor. In seventy cases of sar- 
coma of the femur, analyzed by Gross, there were only two cases in 
which the upper epiphysis was affected. 

The early symptoms in cases in which the head of the femur is not 
primarily involved are very slight, and consist chiefly of a swelling 
which is painless and not fluctuating; limp and slight restriction of 
motion may be present. Soon, however, it becomes evident that the 
enlargement is predominating over all the other symptoms and the swell- 
ing progressively increases, suggesting perhaps hip abscess. Fluctua- 
tion, however, is absent and the swelling embraces the whole circum- 
ference of the limb. There is an enlargement of the superficial vessels 
and the swelling later becomes enormous. The patient becomes ema- 
ciated and wastes away. The affection may be very painful or again it 
may be attended with very little suffering. Amputation at the hip- 
joint, if performed sufficiently early, is the only remedy. 

SYPHILIS. 

Acquired syphilis may present joint manifestations. 

Arthralgia without objective symptoms may occur early in the sec- 
ondary stage. Simple serous synovitis, associated with pain, redness, 
and swelling, may accompany the secondary symptoms. This condition 
may pass on to a chronic hydrops. In the tertiary stage chronic serous 
synovitis may be present. 

These and other processes may be the result of gummata of the ends 
of the bones or in the periosteum or situated about the joints, not nec- 
essarily in any intimate connection. 

Gummatous ostitis is a cause of secondary affections of the joints 
when situated in their neighborhood. On section the bone shows, most 
often in the periphery, a yellowish-gray focus of disease, in appearance 
strikingly like the early stage of focal tuberculosis. But from this lat- 



OTHER AFFECTIONS OF BONES AND JOINTS. 253 

ter it may be distinguished by the absence of any surrounding hyper- 
emia or infiltration, which goes with tuberculous disease. Often, of 
course, these gummata exist along with much synovitis of a character- 
istic type, and a much thickened and diseased periosteum. Gummata 
in the periosteum appear as elastic swellings, rich in fluid, poor in cell 
elements ; later they degenerate to material like pus, and by fatty de- 
generation and absorption, to a cheese-like substance and scar tissue, 
and finally only a thickening remains. 

Secondarily to these periosteal and bone lesions come the capsular 
and synovial thickening and the cartilage degeneration. 1 

Hereditary syphilis is proportionately more often attended by joint 
complications than is acquired syphilis. 2 

The most characteristic form of joint disease in hereditary syphilis 
in children is the osteochondritis of Parrot. This consists in a broaden- 




Fig. 207. Fig. 208. 

Fig. 207.— Ostitis Syphilitica. FlG. 208.— Hyperostosis. (R. H. Fitz.) 

ing of the cartilaginous layer of the epiphysis next to the diaphysis, 
with irregularity of the zone of ossification. At the same time there 
occur thickening of the epiphysis and a growth of granulation tissue, 
sometimes breaking down in the medullary cavity. As a result of this 
process, separation of the epiphysis may occur spontaneously or as the 
result of some trauma. Secondary synovitis is likely to accompany 
this process. This may be of any character and is often purulent, and 
the cartilage may degenerate and soften. Suppuration in general is 
less rare in hereditary than in acquired syphilis. 

The clinical symptoms of this osteochondritis are thickening of bone 
at the epiphyseal line, tenderness, and joint inflammation, secondarily 
with lameness and even uselessness of the limb for a time. It may 

1 N. Y. Med. Jour , February 4th, 1899. 

2 Berl. klin. Woch., 1884, 442.— Lancet, 1886, i.. 391.— Deutsch. Chir., Lief. 66, 
P- 294. 



254 ORTHOPEDIC SURGERY. 

involve several joints. The affection is sometimes spoken of as syphi- 
litic pseudoparalysis of infants. 

Later hereditary syphilis may show a somewhat similar affection, 
due to overgrowth of the epiphysis and spoken of as " chronic osteoar- 
thropathy of hereditary .syphilis" or "false tumor albus." The thick- 
ened and deformed epiphyses form a mass which appears as a spindle- 
shaped swelling (most often at the knee). There is typically no 
muscular spasm, although marked atrophy of the muscles is present. 
Pain is generally absent, although rarely there may be some tenderness 
and local heat. What inflammation of the joint is present is secondary 
and not characteristic. It is favorably affected by the usual treatment 
for syphilis. 1 

Syphilis of the Spine. — Syphilitic destruction of the bodies of the 
vertebrae must be regarded as possible and not unlikely, but the re- 
corded cases of this sort are not in general satisfactory as proving 
pathologically that such a condition has existed. The presence of 
syphilis in a patient with a knuckle in the back does not prove that tu- 
berculosis is absent or that the vertebral destruction is of a syphilitic 
character. 

The occurrence of gummata in the vertebrae or near them in such 
position as to cause pressure on the cord must be admitted, also the 
syphilitic origin of certain vertebral exostoses.' 2 

The diagnosis of syphilitic spondylitis in most cases has rested on 
the slenderest clinical evidence, which cannot be accepted. The case 
reported by Joachimsthal, 2 where a cervical deformity disappeared 
under antisyphilitic treatment, is of interest in this connection. Under 
these circumstances nothing can be said of the clinical course of the 
affection. 

GOUT. 

The joint affection, which is the manifestation of the constitutional 
malady known as gout, ordinarily begins as an acute attack, and is fol- 
lowed by a chronic inflammatory process, increased by constant exacer- 
bations. The synovial membrane first presents the appearances of 
acute inflammation ; the cartilage also shows a tendency to inflamma- 
tory degeneration and erosion, and on its free surface and in its tissue, 
as well as in its capsule and periarticular structures, there appears a 
deposit of acicular crystals of urate of soda, which localized deposits 

1 Borchard : Deutsch. Zeit. f. Chir.. lxi.. no. — Hippell: Munch, med. Woch., 
xxxi., 1903. — Palier: Am. Med., July 18th. 1902.— Dunn and Robinson: Lancet, 
August 1st, 1903. 

-Charcot: Comptes rendus de la Soc. de Biol., 1865, 2S. — v. Bechterew : 
Neurol. Centralbl., 1893, 313. — Foderl und Peham : Deutsch. Zeit. f. Chir., xlv. 
— Amidon: N. Y. Med. Jour.. 1887, 225. 

:; Zeitsch. f. orth. Chir.. xi., 1. 200. 



OTHER AFFECTIONS OF BONES AND JOINTS. 255 



are known as " tophi."' The marginal growths are true exostoses 
and not, as in arthritis deformans, covered by proliferating cartilage. 
There is a permanent thick- 
ening of the synovial mem- 
brane. There is but little 
tendency to suppuration, un- 
less the calcareous deposits 
ulcerate through the skin 
by pressure and so open 
the periarticular tissue. The 
common seat of the affec- 
tion is the metatarsopha- 
langeal joint of the great 
toe (podagra). The joints 
of the hands, and the knee- 
and elbow-joints are also ' ,- . . ; " - . r t „ . 

J blG. 209.— Knee-joint Surfaces m Gout, Showing- 

often affected. Deposits. 




OSTITIS DEFORMANS 



Paget's disease — Osteomalacia chronica deformans hypertrophica— 
Paget 'sche Krankheit. 

These names designate a deformity affecting the long bones, chiefly 




Fig. 210.— Photograph and Radi 



iph of Case of Gout, Showing the Deposits. 



in their diaphyses, and causing them to bend. It most frequently 
attacks the lower extremities first, also involving the spine and the 
skull. The upper extremities are at times curved. The process con- 
sists of a thickening and curving of the affected bones, the bone hyper- 



256 



ORTHOPEDIC SURGERY. 



trophying as a whole and its curves increasing, while the external sur- 
face is roughened. In some cases the enlargement takes place by the 
expansion of the cortex ; in other cases the spongy part of the bone is ex- 
tended. The skull shows marked thickening and enlargement, sometimes 
to four or five times its normal thickness, 
and its surface is rouerh and uneven. 




Fig. 211 -Ostitis Deformans. Male, age fifty-four. First definite signs seven years before 
photograph. Present involvement most marked in cranium, clavicles, right ulna, left 
radius, pelvis, tibiae, and fibiae. (R. B. Osgood.) 

Microscopic examination shows appearances of absorption and new 
formation. The first is shown by the formation of Howship's lacunae, 
and where one finds the formation of new bone it is very poor in lime 
salts. Later deposit of lime salts may occur in this tissue, forming 
thick sclerotic islands in the osteoid tissue. The marrow and vascular 
spaces are increased in extent and the fatty part of the marrow tends to be- 
come fibrous. The proportion of mineral salts in the bones is diminished. 



OTHER AFFECTIONS OF BOXES AXD JOIXTS. 257 



Etiology. — In the matter of etiology nothing- definite has been es 
tablished. The disease at- 
tacks men more frequently 
than women, as was found 
in the analysis of twenty- 
five personal cases by R. B. 
Osgood and W. A. Locke, 
of Boston. 1 They also found 
that the disease began at 
an earlier period of life than 
was previously supposed, 
the average of twenty-one 
cases showing the period of 
onset to be at the age of 
forty-three to forty-four 
years. It is significant that 
in the majority of their 
cases, the disease was as- 
sociated with marked ar- 
teriosclerosis. In five other 
cases there were manifesta- 
tions of arthritis deformans. 
The relation of the two dis- 
eases is obscure, and Rich- 
ard asserts that pathologic- 
all}- they are identical. 2 
This point of view cannot 
vet be regarded as estab- 
lished. 

Symptoms. — The affec- 
tion is generally ushered 
in by a long period of pain 
described as " rheumatic " 
and by headaches. 3 Some 
cases are, however, practi- 
cally painless. In cases of in- 
volvement of the skull neu- 
ralgia from pressure may be 
present, but the reflexes and 
electrical reactions remain normal. The general condition of the patient 
is often not seriously affected. The attitude is characteristic, the patient 

1 Paper not as yet published. 

2 "Hdbch. der orth. Chir.." Joachimsthal. Jena, 1904. p. 81. 
;; Wallenberg : Zeitsch. f. orth. Chir.. xiii.. 1. 
i7 




Fig. 212. — Lower Leg, Ostitis Deformans. Bowing' and 
lamellar thickening of tibia and fibula. Areas of 
rarefication or true cavity formation with apparent 
periosteal overgrowth and cortical increase. Coarse 
trabeculation and partial obliteration of medullary 
cavity. Marked arteriosclerosis. (R. B. Osgood.) 



258 



ORTHOPEDIC SURGERY. 



stands with the legs bowed and the spine bent in a gradual backward 
curve, the body is carried forward bent at the hips, and the skull is greatly 
enlarged. The gait becomes clumsy and stiff, the head drops tow- 




FlG. 213.— Ostitis Deformans. Marked involvement of left radius and right ulna. Character- 
istic coarse trabeculation and lamellar thickening with irregular periosteal outline. Med- 
ullary cavity obscured or obliterated. Beginning process in proximal phalanx of left 
thumb and right os magnum. Arteriosclerosis of many vessels. (R. B. Osgood.) 

ard the chest, and the shoulders are round and stooping. The spine 
loses its flexibility and becomes more or less rigid. Scoliosis may oc- 
cur in the spine of a moderate degree. The body is shortened in the 
erect position, and the backward curve of the spine and the attitude 



OTHER AFFECTIONS OF BONES AND JOINTS. 259 

resemble that of spondylitis deformans. In ostitis deformans, however, 
the joints are as a rule exempt, and the diagnostic symptoms are the 
occurrence of bow-legs beginning in the latter half of life, the bending 
backward of the spine, the hypertrophy of the bones, and especially the 
great thickening of the skull. Fractures occur rarely, and in the cases 
observed (Smith, Taylor, Kedder, Bradford) they united readily. 

Prognosis. — The prognosis of the affection as far as life goes is not 




FlG. 214. — Charcot's Disease of Right Knee-joint. (Weigel.) 

unfavorable, and death generally occurs from intercurrent affections. 
No satisfactory treatment has been formulated. Protective apparatus 
in the severer deformities may be necessary, but they increase muscu- 
lar weakness and are to be avoided if possible. 

PATHOLOGICAL CONDITIONS OF THE NERVOUS SYSTEM. 

Charcot's joint disease, spinal or neuropathic arthropathy, neural 
arthropathy, tabetic arthropathy, etc. 

A destructive form of joint disease may be associated with locomo- 
tor ataxia, syringomyelia, Pott's disease, acute myelitis, injuries of the 



260 ORTHOPEDIC SURGERY. 

peripheral nerves, cerebral apoplexy, tumors of the cord, crushing of 
the spinal cord, progressive muscular atrophy, and anterior poliomye- 
litis. 

The pathological process is in many respects similar to that in ar- 
thritis deformans, except that the destructive process is more rapid and 
the formative activity less. The cartilage disintegrates, the ends of the 
bones are exposed and may be rapidly worn away, the synovial mem- 
brane and ligaments thicken and ulcerate. This process may result in 
spontaneous luxation in severe cases. Synovial effusion may be pres- 
ent, and suppuration may occur. Hypertrophy of the epiphyses may 
take place as well as the formation of osteophytes, but atrophic changes 
predominate. The essential character of the affection is the rapid 
melting away of cartilage and bones, and the joint changes may be 
present at an early stage of the nervous disorder. 

The affection is most often monarticular, and although adults are 
generally affected, cases have been recorded as early as the sixth year. 
The joints are affected in approximately the following order of fre- 
quency: knee, hip, shoulder, tarsus, elbow, ankle, wrist, jaw, and 
spine. 

Swelling, effusion, disability, and sometimes pain are the first signs 
of the joint involvement. Spontaneous arrest of the process may occur, 
and ankylosis may rarely result. More commonly, however, the joint is 
disorganized to the point of luxation. The diagnosis is often difficult, 
especially in the early stages. 

The treatment does not differ essentially from that of inflamed 
joints in general. The nervous lesion must be treated, and although 
excision of the joint has been successfully done under these conditions, 
local operative measures are not, as a rule, to be advised. In cases in 
which syphilitic history is present, mercury or iodide of potassium 
should be given. 

Arthropathy of the vertebral column has been rarely observed in 
tabes. It is manifested by a deformed position of the column, shown 
by scoliosis and backward bending of the spine. 1 Partial relief may 
be afforded by fixation. 

Arthropathy of the Hip. — In frequency of attack the hip comes next 
to the knee, which among the large joints is the one most often affected. 
As in most other instances, Charcot's disease of the hip simulates very 
closely arthritis deformans of the ordinary type. The changes in the 
joint are, however, much more acute and extensive than those with 
which we are familiar in arthritis deformans. Synovial effusion is a 
more prominent symptom, sometimes reaching the stage of a large 
fluctuating tumor which presents itself at the front and the back of 

1 Spiller : Am. Medicine, November ist, 1902, p. 701 (with bibliography).— 
Graetzer: Deutsch. med. Woch., December 24th, 1903. 



OTHER AFFECTIONS OF BONES AND JOINTS. 261 



the joint, with a wearing away of the head of the bone. The trochan- 
ter ascends and a state of affairs similar to the condition found in late 
hip disease is presented. In the matter of diagnosis, of course one de- 
pends upon the coexistence of symptoms of spinal-cord disease. As to 
treatment, little can be accomplished ; in cases in which swelling is ex- 
cessive, aspiration of the joint sac may give temporary relief. Rest 
is indicated for the joint, with traction if 
it gives relief. 

HAEMOPHILIA. 

Haemophilia is accompanied at times 
by characteristic joint lesions, which in 
their clinical resemblance to tuberculosis 
are worthy of notice. 1 The knee is the 
joint most frequently affected. Like 
other manifestations of this diathesis, 
joint affections occur most often in male 
children or young adults, decreasing in 
frequency with increasing age. The hem- 
orrhage may be intraarticular or periar- 
ticular. After repeated acute attacks of 
hemorrhage into the joint, chronic joint 
changes are likely to ensue. There is an 
overgrowth of brown-stained synovial 
tufts. The cartilage may degenerate, 
and sharp-bordered defects in it are fre- 
quently found. Adhesions, contractions 
of the capsule, and bony displacements 
may occur. Erosion of the ends of the 
bones ma)" take place along with a pro- 
liferation at the edges not unlike arthritis 
deformans. A brown staining of all the 
joint structures, except the cartilage, is 
described as characteristic. 

Rheumatic pains are a common clinical accompaniment of the affec- 
tion, and its character is essentially chronic. Swelling and muscular 
spasm are present during attacks of irritation, and the diagnosis from 
tuberculosis is to be made more from the history than from any char- 
acteristic features." 




FIG. 215. —Disease of Right Knee- 
joint of Six Years' Duration Due 
to Haemophilia. Showing Swell- 
ing and Flexion Deformity. 



1 Am. Medicine. March 21st. 1903. editorial. — Carless (with analysis of 253 re- 
ported cases): Practitioner. 1903. lxx.. 85. 

-Linser: Bruns' Beitr. zur klin. Ch.. Bd. xvii.. 105. — Yolkmann's Samml. 
klin. Yortrage (Transl. Med. Surg. Reporter, lxvi.. Xo. 26. p. 999). — Gocht : 
Munch, med. Woch.. 1899. February 21st. 271. 



262 



ORTHOPEDIC SURGERY. 



General treatment offers but little hope, although the use of gelatin 
by mouth, in doses of six or more ounces daily, has been found of use. 1 




FlG. 216.— Clubbing of Fingers in Secondary Osteo-arthropathy. 

Protection to the diseased joints is of more use than any other one 
measure, but the prognosis as to recovery is doubtful at best. Aspira- 
tion with a small needle may be safely done for purposes of diagnosis. 2 




Fig. 217.— Secondary Osteo-arthropathy Due to Pott's Disease, Showing Enlargement of 

Liver and Spleen. 

Fatal hemorrhages have occurred as the result of operation on these 
supposedly tuberculous joints. 

1 Hesse: Ther. der Gegenwart, September, 1902; Practitioner, 1903, lxx., 85. 
- For normal processes of absorption of blood in joints see Jaffe : Langen- 
beck's Archiv, Bd. liv., Hft. 1. 



OTHER AFFECTIONS OF BONES AND JOINTS. 263 

SCURVY. 

Joint affections in infantile scurvy are not uncommon, and simu- 
late closely epiphysitis. The enlargement may be confined to one of 
the bones forming an articulation. The thickening is due to periarticu- 
lar or rather subperiosteal hemorrhage, and the joint itself is not usu- 
ally affected, though hemorrhage may occur. Such joints yield readily 
to the usual treatment of infantile scurvy. Such apparent inflammation 
of joints occurring in scurvy is regarded as being more often due to 
extraarticular than to intraarticular lesions, subperiosteal hemorrhage 
being the most frequent lesion. In 379 cases of scurvy investigated by 
the American Pediatric Society 1 there were swellings in, or more often 
about, the joints in 165. These were distributed as follows: Knee, J^; 
ankle, 28; wrist, 12; hip, 6; shoulder, 5; elbow, 3; hand, 1. 

In 40 analyzed with regard to the coexistence of rickets, in 45 per 
cent there were symptoms of rickets, while in 55 per cent rickets was 
said to be definitely absent. 

SECONDARY HYPERTROPHIC OSTEO-ARTHROPATHY. 

This is the name given to a condition occurring sometimes in con- 
nection with chronic pulmonary disease, in which the fingers are clubbed 
and stiffened, the shafts of the bones are thickened, and the spine is 
bent forward in a kyphosis. It occurs sometimes in connection with 
Pott's disease. The relation of the affection to acromegaly and osteo- 
malacia is not clear. 

In this condition the joints are occasionally swollen and painful with 
effusion. The changes as shown by autopsy 2 are synovitis and thinning 
of the articular cartilages even to the extent of exposing the bone. 
Along with this is associated periostitis and some sclerosis of bone 
which may involve the shaft. 

GROWING PAINS. 

A joint affection incident to growth has been described by Bouilly, 
and has long been known but unclassified by practitioners, and popu- 
larly considered to be incident to growth — "growing pains." There is 
slight pain chiefly in the juxtaepiphyseal region, most commonly near 
the lower epiphysis of the femur. This pain is brought on by fatigue, 
strains, or exposure. In the lightest cases the symptoms pass away in 
a few hours. In severer forms they may last for several clays, and the 
pain may be accompanied by slight fever. In the severest form the 

1 Boston Med. and Surg. Jour., vol. cxxxviii.. 607. 

- Lefebre : These de Paris, 1891. — Ranzier : Rev. de Med., 1S91, p. 30. — Whit- 
man: Pediatrics, 1899. vii., Nos. 4 and 5 (with bibliography). — J anew ay : Am. 
Journ. Med. Sci., October, 1903 (with bibliography). 



264 



ORTHOPEDIC SURGERY. 



affection may continue for months. There may be slight effusion in 
the joints, but recovery eventually takes place. It may occur during 
the ages between five and twenty-one. 

A great amount of harm is done in referring to this class the pains 
of beginning chronic joint disease. Growing pains proper are neither 
severe nor permanent. 

Analogous to this may be mentioned what has been termed by 
French writers maladie de la croissance — which is in reality a hyper- 
emia and sensitiveness of the epiphysis in adolescents — analogous to 
what is seen occasionally in rickets. 

ACTINOMYCOSIS. 

Actinomycosis is a specific infectious disease occasionally attacking 
the bone secondarily, and is caused by the streptothrix actinomycotica 
(ray fungus). The process in the bone is a destructive one. 




. 




Fig. 



-Myositis Ossificans. (Michelson.) 



The spinal column, ribs, and sternum may be attacked, but the 
maxilla is the bone most frequently affected, and the whole affection 
is to be regarded as one attacking the soft parts, the involvement of 
bone being only secondary and incidental. The source of the infection 
is through the gastrointestinal or respiratory tract, and the persons 
commonly affected are those who live in the country and handle grain. 1 

Actinomycosis of the spine is rare, but few cases having been re- 

1 Ruhrah : Annals of Surgery, vol. xxx., p. 417. — Von Braez : Annals of Sur- 
gery, vol. xxxvii.. p. 237- — Acland : Lancet, 1886, p. 973. 



OTHER AFFECTIONS OF BONES AND JOINTS. 265 

ported. It may be destructive, resembling Pott's disease. In a case 
seen by one of the writers, in which the upper dorsal region was affected, 
there was an extensive induration of the neck and shoulders and the 
skin was riddled by sinuses. The constitutional disturbance was very 
marked, as shown by anaemia and prostration. The early symptoms 
had been similar to those of Pott's disease, and there was flattening of 
the back of the neck. The diagnosis was made by microscopic exami- 
nation of the discharge from the sinuses. 

The treatment consists in the administration of iodide of potassium. 

In the writers' case progressive improvement in symptoms followed 
the use of this drug. 

Echinococciis cysts of the spine have been observed. 1 

MYOSITIS OSSIFICANS. 
This affection in its symptoms is closely enough allied to those 
caused by certain joint diseases to require mention. The pathology of 




Fig. 219.— Radiograph of Same Case Showing Irregular Deposits of Bone. (Michelson.) 

the disease consists of the formation of bone tissue in the connective 
tissue surrounding the muscles. This is of the periosteal type and 
occurs in plates or irregular shapes. The affection is one largely af- 
fecting children and its cause is unknown. Trauma is a cause of many 
cases, and at times the disease is progressive, attacking one muscle 
after another. The affection is most commonly found in the forearm, 
leg, or thigh, but any muscle may be involved. 

'Friedberg: Schmidt's Jahrb.. 1897.— Brims' Beitr.. xi., 1894. 



266 ORTHOPEDIC SURGERY. 

The affection is manifested clinically by the appearance of tumors 
involving the muscle, which may or may not be painful. Fever may 
be present or absent. The muscles involved are stiffened and may be- 
come useless, while at other times but little inconvenience is felt. 

No satisfactory treatment has been formulated and no measure has 
been found to control the disease. The tumors may be excised. 1 

ANKYLOSIS. 

Ankylosis is the name used to characterize the persistent stiffness 
of a joint. This may be "complete " when all motion is lost, or "par- 
tial" or "incomplete" when some part of the normal motion remains. 
It is also classified as " bony " or " fibrous " ankylosis, according to the 
character of the tissue binding together the joint surfaces. False an- 
kylosis, pseudo-ankylosis, etc., are terms used to designate a condition 
of joint stiffness in which the restriction of joint motion is due, not to 
destruction of the joint surfaces, but to other causes, such, for example, 
as the development of osteophytes and the like around the edges of the 
joint occurring in arthritis deformans, the contraction of the joint cap- 
sule, etc. 

The name ankylosis should not be applied to the stiffness of joints 
due to the tonic muscular spasm of acute or chronic joint disease. This 
disappears under anaesthesia, whereas ankylosis is not affected by it. 

The pathology of ankylosis is the pathology of the affections which 
cause it. It represents in general the end result, the cicatrix, of an 
acute or chronic joint inflammation or of a more or less severe trauma. 
True ankylosis in all cases consists of the formation of fibrous tissue 
connecting the ends of the joint, which later is apt to undergo bony 
transformation. The cartilage, if not originally destroyed by the dis- 
ease, degenerates from disuse, and in the severer cases the entire ends 
of the bones are connected by fibrous bands, and later by a solid mass 
of bone. In such cases the cortical parts of the ends of the bones 
forming the joint may be absorbed and the medullary cavity may extend 
uninterrupted from the leg to the thigh, for example. In such cases 
the joint is wholly obliterated, and the leg and thigh form one continu- 
ous bone. 

Stiffness of joints may also result from adhesions between the syn- 
ovial membrane, from contraction of the capsule and ligaments, from 
adhesions between the tendons and their sheaths, from periarticular 
cicatrices due to abscesses and trauma, from marginal ecchondroses and 
exostoses, from the ensheathing formation of new bone, the alteration of 
joint surfaces in arthritis deformans, and from fractures and dislocations. 

1 Binine : Annals of Surgery, 1903 (report of 86 cases).— C. Rothschild : Beitr. 
z. klin. Chir., xxviii., 1.— Michelson : Zeitsch. f. orth. Chir., xii., 3 (with bibliog- 
raphy). 



OTHER AFFECTIONS OF BONES AND JOINTS. 267 

The causes of acquired ankylosis are therefore to be found in acute 
or chronic joint inflammation, in the ankylosing form of arthritis de- 
formans, in fractures involving the joints, in trauma of various kinds, 
and in periarticular suppuration and trauma. The fixation of normal 
joints for any reasonable time does not cause true ankylosis. 1 

Ankylosis may occasionally occur as a congenital condition. 

The joint may be stiffened in any part of its normal arc of motion. 
Ankylosis is more common in a deformed than in a straight position, 




Fig. 



-Pseudo-ankvlosis of Hip-joint Due to Arthritis Deformans. (Joachimsthal.) 



when it is the result of chronic joint diseases. The position in which 
it occurs is of great importance, as the usefulness of a limb in cases of 
irremediable ankylosis will depend on stiffness in a useful position. 

In the hip ankylosis is likely to occur in flexion and adduction. 
The desirable position for ankylosis of the hip is in a few degrees of 
flexion with no adduction or abduction. 

In the knee ankylosis generally occurs with flexion of the leg with sub- 
luxation of the tibia. The useful position is with the leg nearly straight. 

1 Reyher : Deutsch. Zeit. f. Chir.. iii.. 1873. 



268 



ORTHOPEDIC SURGERY. 



In the ankle the desirable position for a stiff joint is with the foot 
at a right angle to the leg. 

In the shoulder the arm is most useful if slightly abducted and a 
little flexed. 

With a stiff elbow the only useful arm is obtained with the forearm 
at a right angle to the arm. 

The diagnosis of ankylosis is made by the absence or limitation of 
motion. It is not diminished by anaesthesia, and the ;r-ray shows the 




FIG. 221.— True Ankylosis of Hip-joint Due to Tuberculous Dii 



(Warren Museum.) 



disappearance of the line between the bones and the continuity of bony 
structure in bony ankylosis. 

The prevention of ankylosis consists in the efficient treatment of 
the affections likely to cause it. 

The treatment of ankylosis when the union is not bony naturally 
differs from that when the ends of the joint are connected by bone. In 
the latter case non-operative treatment is useless. 

In incomplete ankylosis an attempt may be made to stretch the 
connecting structures and thus increase the amount of motion. 

Manual StretcJiing. — This may be done by gradual manual stretch- 
ing, in which gentle manipulative force is used at short intervals and 
repeated daily. If too much force is used, inflammatory reaction will be 



OTHER AFFECTIONS OF BONES AND JOINTS. 269 

started in the joint, and the condition will be made worse. The use of 
a proper degree of force should be followed by a daily increase of joint 
motion without great pain. 

Mechanical Correction. — The attempt at stretching maybe made by 
means of a pendulum apparatus, in which a carefully controlled rhyth- 
mical movement is exerted to any desired extent. The Zander appa- 
ratus may be used in a similar way to increase the range of joint motion. 

Local Measures. — Certain measures affecting the local circulation 
seem to aid in restoring flexibility in connection with the stretching 
mentioned above. These are Bier's congestive method, hot-air baths, 
massage, and vibratory massage. 

This treatment is suited to the stiffness following fractures and 
joint injuries, the loss of motion in arthritis deformans, and after non- 
tuberculous inflammations in and around the joints. 

Forcible Stretching. — Incase these measures prove ineffectual the 
patient should be anaesthetized and the arc of motion of the stiffened 
joint increased by the use of moderate force to stretch or break the 
adhesions existing. This should be followed by rest to the joint for 
one or two days, followed by the resumption of the gentle measures 
described. The injudicious use of force, as a rule, does more harm than 
good by exciting inflammation and causing new adhesions. After the 
use of manipulative force the joint should be fixed in the position of 
greatest usefulness, described above. 

In the case of bony ankylosis these measures are of no value. 

If the ankylosis has occurred in a position of deformity, the joint 
should be corrected and the limb placed in a useful position by osteot- 
omy or excision. . 

Osteotomy is, as a rule, linear, and is generally performed just above 
or below the joint surface. Wedge-shaped osteotomy inevitably short- 
ens a limb, but may be required in cases of extreme deformity. 

Excision may be done at the site of an ankylosed joint, not with a 
view of restoring motion, but to correct deformity. The planes of the 
resected ends of the bones should be so placed as to give the desired 
position of the joint after union. 

The application of these methods to the especial joints has been 
discussed in connection with each joint. 

Formation of New Joints.— In bony ankylosis the formation of a 
new joint at the site of the former one may be attempted. The method 
of interposing a layer of fascia or other foreign substance between the 
resected ends of the bone in cases of true bony ankylosis has been 
described and successfully carried out with marked success, especially 
by Murphy, 1 of Chicago. The hope of success in the operation depends 
upon the fact that aponeurosis attached to fatty tissue when subject to 
1 Murphy : Trans. Am. Surg. Assn., xxii.. 315 (with literature). 



2/0 ORTHOPEDIC SURGERY. 

pressure tends to form an hygroma or bursa. If, then, the line of union 
where the joint formerly existed is chiselled or cut through in approxi- 
mately the original joint plane, and aponeurotic, or muscular, and fatty 
tissue is interposed, there is hope of a restoration of joint motion in 
place of the former bony ankylosis. The capsule and synovial mem- 
brane, if the latter remains, are extirpated and only essential bands of 
ligaments are left. Bony outgrowths are removed, adherent tendons 
freed, cicatricial contractions cut out, and a flap of the desired tissue is 
taken from the neighborhood and turned in between the ends of the 
bones. This flap should be secured to the edges of the capsule and is 
left attached by its base. Use of the limb is at first painful, and passive 
motion under anaesthesia may be required. Murphy reports a series of 
successful cases in various joints. The causes of failure he enumerates 
as follows : 

i. Insufficient or defective exsection of synovial membrane, cap- 
sule, and ligaments. 

2. Insufficient interposition of fat and aponeurosis or muscle be- 
tween the separated bony surfaces. 

3. Infection. 

4. Sensitiveness to pain in motion after operation 



CHAPTER IX. 
RICKETS, KNOCK-KNEE, AND BOW-LEGS. 

Rickets.— Definition. — Pathology. — Occurrence and Etiology.— Symptoms. — Di- 
agnosis. — Prognosis. — Treatment. 

Osteomalacia. — Chondrodystrophia fee talis. — Fcetal rickets. 

Knock-knee. — Occurrence and etiology. — Symptoms.— Diagnosis. — Treatment. — 
Expectant. — Mechanical. — Operative. 

Bow-legs. — Occurrence. — Causation. — Symptoms. — Diagnosis. — Prognosis. — 
Treatment. — Expectant.— Mechanical. — Operative. 

Rhachitic curves in the upper extremity. — Improperly united fractures. 

RICKETS. 

Definition. — Rickets is a constitutional disease which affects young 
children. Its chief characteristics are manifested in the osseous sys- 
tem, where there is a local or general disturbance of the normal proc- 
ess of ossification, as a result of which the epiphyses become enlarged 
and the affected bones become soft and pliable ; growth is delayed and 
deformities of a serious character arise. The affection itself does not 
belong to the category of surgical diseases ; but the resulting deformi- 
ties demand strictly surgical treatment, and it is important that the sur- 
geon should familiarize himself with the leading features of the affec- 
tion. 

The disease is known in English as rickets or rhachitis. Other 
names for the affection are : morbus anglicus, articuli duplicati, eng- 
lische Krankheit, Zwiewuchs, doppelte Glieder, nouure, rachitisme, etc. 

Pathology. — Rickets occurs especially at the time when the bone 
growth is at its maximum, and its most obvious feature is a defective 
calcification of the bones, in consequence of which secondary changes 
occur. 

In rickets the pathological changes are most marked at the junction 
of the epiphysis and the shaft. The epiphyseal cartilage, which should 
normally be a thin layer, in rickets appears as a broad, reddish-gray, 
translucent cushion, w T hile the whole epiphysis is enlarged. 

The line of calcification is thin or may be wanting in places, the for- 
mation of medullary spaces extends into the zone of calcification and 
possibly through it, and the deposit of bone inside these spaces is want- 
ing or irregular, its place being taken by "osteoid tissue." 

The periosteum of the shaft is hyperaemic and thickened and boggy 
and often adherent to the bone. The subperiosteal layer, which nor- 

271 



272 



ORTHOPEDIC SURGERY. 



mally is thin and scarcely noticeable, in rickets is thick and appears 
dark and like spleen pulp. 

The medullary bone is more hypersemic than normal medulla at this 
age. The intercellular substance may show mucoid degeneration or be 
fluid. It does not seem that lime is dissolved out of the finished bone, 

but that resorption of 
such bone in toto is the 
important element. Aft- 
er the active process has 
ceased lime is deposited 
in the " osteoid tissue," 
and the result is a thick 
and heavy bone. 

The chemical analysis 
of rhachitic bone shows a 
percentage of nineteen to 
fifty-three per cent of ash. 
Ossification after the 
process is over becomes 
excessive and may be 
spoken of as petrifaction 
or eburnation, rather than 
true ossification. Infrac- 
tions or partial fractures, 
with the break on the 
concave side of the long 
bones, may occur. The 
ligaments become re- 
laxed and stretched, and 
the muscles flabby from 
disuse. The spleen is 
ordinarily enlarged and 
sometimes the liver. Ca- 
tarrh of the alimentary ca- 
nal and bronchi are com- 
mon accompaniments. 
In rickets of the skull the meninges and brain may be secondarily 
affected. 

Occurrence and Etiology. — Rickets is an affection occurring com- 
monly during the first dentition. Cases of rickets are, however, de- 
scribed as congenital and others as occurring during adolescence. 

Congenital rickets, or fcetal rickets, will be discussed under the head- 
ing of clwndodystrophia fcetalis . 

Rickets in CJiildhood. — The common time of occurrence is in early 




FIG. 222- Skeleton in Rickets. (Warren Museum.) 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 273 

childhood, especially in the first two years of life. In a series of 400 
medical out-patients consecutively investigated at the Infants' Hospital, 
Boston, 318 showed signs of rickets, and in 106 of these the children 
were in their first six months, 134 between six and' twelve months, and 
the remainder between one and two years. 1 

The rickets of adolescence or late rickets is a disease which affects 
persons at about the age of puberty ; 2 it may be 3 associated with albu- 
minuria, and its etiological relations are decidedly obscure. The physi- 
cal signs are the same as in the rickets of early life, except that the 
epiphyseal enlargement is generally not so great. In several cases 
reported dissection of the skeleton showed the same characters as in 
early rickets. 4 

In 2,595 cases of rickets reported from various authors, there were 
1,337 boys' to 1,258 girls. 

Causation. — Rickets is an affection of faulty nutrition. It is much 
more prevalent among the crowded poor of the cities than in rural com- 
munities, and certain races seem to be more subject to the affection 
than others. The children of the negro, Italian, and Portuguese poor 
are more frequently afflicted than the Irish in our Atlantic American 
cities. 

As might be expected, the later children of a large family are much 
more liable to rickets than their older brothers and sisters. 

Inasmuch as rickets is a disease of malnutrition, the commonest 
causes are to be sought in the immediate surroundings of the patient. 

Bad hygienic influences, such as poor ventilation and food, damp 
dwellings, crowded rooms, etc., have a very marked influence in pro- 
ducing rickets. 

The most evident cause other than bad environment is faulty feed- 
ing. The disease is much less common in breast-fed than in bottle-fed 
children. In the latter, even if carefully nurtured, slight evidence of 
rickets is not infrequently seen in late dentition or enlarged epiphyses, 
and occasionally in slight curves in the long bones. 

As to the theories of the causation of rickets, the reader is referred 
to books on the diseases of children. 

Artificial farinaceous foods contain a very much smaller percentage 
of fat than milk does, and the experience at the London Zoological 
Gardens lends much weight to the idea that the deprivation of fat and 

] J. L. Morse: Journ. Am. Med. Assn.. March 24th. 1900. 
2 Lucas : Lancet. June 9th. 18S3. 

3 Keetly: Annals of Surgery. — Palm: Practitioner, xlv.. 1890. p. 275. — Du- 
play : Gaz. des Hop.. 1891. p. 1397. — Robert Jones: Brit. Med. Journ.. 1896. i., 

34i- 

4 Moxon: Guy*s Hospital Reports. 1878. — St. Thomas* Hospital Reports, 
vol. xiv. 

18 



274 ORTHOPEDIC SURGERY. 

proteids from the diet of young animals is a most important factor in 
the production of rickets. In menageries, where animals live under 
highly artificial conditions, rickets attacks young lions especially, and is 
the cause of death in a large number of cases. Ostriches, pheasants, 
and poultry under the same conditions have a softened condition of the 
bones. 

The subject of the relation of syphilis to rickets must be passed over 
very briefly, as having only an incidental interest in this treatise. The 
present view rather regards syphilis as an indirect cause of rickets in 
impairing the general constitution. The common experience is to find 
a small proportion of syphilitics among rhachitic children. 

Chronic tuberculosis in the parents, as well' as debility from any 
cause impairing the nutrition, may be the cause of rickets. Any ex- 
hausting disease in the child may be followed by rickets, while bronchi- 
tis is too common a symptom of rickets to be considered its cause, as 
some writers would do. Finally, in certain rare cases no cause can be 
assigned for the occurrence of the affection. 

Symptoms. — The disease is so often the outcome of a long period of 
ill-health that it is difficult to say when the rhachitic symptoms begin. 
Among the commonest early symptoms are restlessness at night, pro- 
fuse sweating, especially of the head, and constipation perhaps alternat- 
ing with diarrhoea, but the diagnosis cannot be made from the premon- 
itory symptoms. 

The belly becomes large and distended with symptoms of imperfect 
digestion and faulty assimilation. In the severer cases the child may 
suffer great pain on being moved. 

The so-called "paralysis of rickets" is at times an accompaniment 
of this stage, and is generally brought to the parent's notice by the 
child's inability to use the limbs. The thighs and upper arms are the 
regions most commonly affected. There is no lesion of the nervous 
system in these cases, and a careful examination in the recumbent posi- 
tion shows that the child's muscular movements are impaired from the 
pain caused by movement. The disability is to be attributed to the 
muscular weakness and the bone tenderness, particularly to a periosteal 
tenderness at the muscular insertions. The electrical reaction is nor- 
mal and the reflexes are not affected. This pseudo-paralysis is an early 
symptom of rickets, and as a rule precedes any marked osseous change, 
which adds to the difficulty of its recognition. The most difficult affec- 
tion from which to distinguish it is the disability due to simple weak- 
ness in non-rhachitic children. 

Fever is most often absent or due to some complication, such as 
bronchitis. Convulsions may occur at any stage of the disease, espe- 
cially when there is any tendency to craniotabes. 

Changes in the Bones. —Enlargement of the epiphyses appears, 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



275 



especially at the wrists and anterior ends of the ribs. Enlargement of 
the lower end of the radius and ulna is practically universal, whereas 
enlargement of the lower end of the tibia and fibula is less frequent. 
These enlargements do not involve the joints. At the ribs one finds 
the "rosary," a series of bead-like enlargements easily felt at the junc- 
tion of the cartilages and the ribs, and a small degree of epiphyseal en- 
largement is easily detected here, and not likely to be mistaken for 
anything else. When these changes 
have occurred, the bones have al- 
ready softened and curvatures of the 
long bones may have begun. In the 
deep-seated epiphyses, like the hip 
and shoulder, one does not notice 
the change. 

The forces that work to produce 
deformity in the softened bones are 
muscular action, gravity, pressure 
from weight, atmospheric resistance, 
and the pressure exerted on bony 
structures by growing organs. 

The typical head of rickets has 
a high, square, prow-shaped fore- 
head, with a decided prominence of 
the lateral parts of the frontal bones 
(frontal eminences) and sometimes 
the parietal eminences as well. 

The anterior fontanel, which 
should normally close at about the 
eighteenth month, remains widely 
open and does not ossify until per- 
haps the third year or even later 
This, however, is not enough to 
establish the fact that the child is 
rhachitic until the age of two years has been reached. The posterior 
fontanel sometimes remains open for months. 

The name era niotabes is applied to an abnormal thinness of portions 
of the parietal and occipital bones. 

Hyperemia of the brain and meninges may be an accompaniment. 
With this hyperemia comes the likelihood of hydrocephalus, either ex- 
ternal or internal, and the accompanying cerebral changes, so that hy- 
drocephalus becomes a complication of rickets which is not very rare. 

Deformities of 'the cJiest are among the most common produced by 
rickets and they occasionally exist without any well-marked signs of 
rickets elsewhere. It is not unusual to see young girls about the age 




FIG' 223. — Case of Rickets Showing De- 
formity of Chest and Enlarged Abdo- 
men. (J. S. Stone.) 



2/6 ORTHOPEDIC SURGERY. 

of puberty who have discovered some inequality in the chest or promi- 
nence of the lower ribs perhaps, but who present no other signs of 
rickets. In these cases it seems reasonable to assume that a slight de- 
gree of bone softening existed in childhood and passed away without 
leaving any other sign than the chest malformation. 

In a typical rhachitic chest the clavicles are shorter and more curved 
than they naturally should be. The chest is narrow and prominent in 
front ; it shows the effect of lateral compression, and the sternum pro- 
jects so prominently that the name of pigeon breast, or pectus carina- 
tum, is commonly given to it. The weakest part of the chest cavity is 
at the junction of the ribs and cartilages, and it is here that the chief 
yielding takes place and the ribs allow themselves to be pressed in lat- 
erally, while the sternum is pushed forward. Again, one side may 
yield more than the other and a prominence of the front part of the 
ribs on one side of the sternum may be the only deformity. A trans- 
verse depression in the chest known as Harrison's sulcus also occurs 
in the typical cases. It is most evident just below the nipples. The 
prominence of the abdomen, which is almost universal in well-marked 
rickets, adds to the deformity of the chest by the elevation of the lower 
ribs, on account of the underlying distention. When the abdominal 
distention disappears, this flaring of the lower part of the ribs is some- 
times left behind. 

A very common deformity of the spinal column due to rickets is a 
backward bowlike curve (involving the dorsal and lumbar regions). It 
is a uniform flexion of the whole column and is most prominent at the 
junction of the dorsal and lumbar regions. This attitude seems the 
result of a long-continued sedentary position, with a weakness and ten- 
derness of the muscles, which fail to hold the spine in the erect posi- 
tion. Rhachitic children, as a rule, learn to walk late, and this peculiar 
flexion seems a persistence and exaggeration of the position which the 
spine naturally assumes in young babies, who are propped up in the 
sitting position. The curve of the spine is usually rounded rather than 
sharp, and the prominence is not limited to one vertebral spinous proc- 
ess, as is the case in early Pott's disease. 

The rhachitic curve of the spine is, as a rule, flexible if the child lies 
upon its face and is lifted by the legs. In the acuter stages and after 
marked bone changes have taken place some stiffness may be seen. 

Scoliosis is a common deformity due to rickets, which has already 
been considered. 

Lordosis is the third of the common spinal deformities due to rick- 
ets, and gives rise to a characteristic attitude, the importance of which 
is much overlooked. 

The attitude of a child affected with well-marked rickets is charac- 
teristic. It exists in most marked cases of knock-knee and bow-legs 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



277 



and sometimes in a less degree with milder grades of the affection. 
The child stands with the legs apart, the thighs flexed and the knees 
bent, the back is arched, and the shoulders are thrown back. The cause 
of this attitude has never been quite clearly established. It is un- 
doubtedly in a measure the persistence of the infantile attitude, the 
position which children assume who are just learning to walk. Another 
factor is the protuberant abdomen, the weight of which the child seems 
to counterbalance by leaning backward. 

Deformity of the pelvis is induced by rickets, because the body 
weight is borne by a bony arch which has lost part of its supporting 




FlG. 224. — Deformity of Spine in Rickets. 



power and bends under weight. These pelvic deformities have only a 
significance in regard to obstetric surgery ; they occasion no trouble or 
noticeable deformity in themselves, but in females, when pregnancy 
comes on, their existence is a matter of the gravest importance. The 
subject is treated in books upon obstetrics. 

Except in very severe cases, the arm bones are not seriously curved. 
The curvatures follow no especial rule, but generally they are an exag- 
geration of the normal curves of the bones. The curvature of the arm 
bones may be due to creeping or to lifting the child continually by 
taking hold of the forearm in one place, but often apparently is the 
result of muscular action. 

Coxa vara may exist in the hips. The condition will be described 
in chapter X. 



278 



ORTHOPEDIC SURGERY. 



The rhachitic deformities of the legs are of such importance that 
they will be considered under the separate headings of knock-knee and 
bow-legs. 

Flat-foot is a very common accompaniment of rickets. The affec- 
tion is considered under flat-foot. 

In general, the skeleton is not only deformed but stunted, and per- 
sons who have rickets severely in childhood do not reach average size 





Fig. 225. — Attitude of Severe Rickets, 
Showing Lordosis and Rotation of 
Pelvis. 



FlG. 226.— Extreme Deformity from Rickets. 



in adult life, as a rule. The osseous deformities, in most cases, persist 
to a certain extent through life. Notably is this true of the shape of 
the skull and the chest. 

Important symptoms relate to the eruption of the tcct/i ; not only 
are they late and irregular, but they are imperfect generally, and unable 
to resist decay. On the average the first tooth appears about the ninth 
month, and not only is the interval between the teeth longer, but the 
order of appearance is often abnormal. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 279 

Diagnosis. — The diagnosis in fully developed rickets is simple ; but 
when the affection is beginning, its recognition may be attended with 
difficulty. 

In beginning rickets certain symptoms are suggestive; these are 
restlessness and sweating at night, and especially universal tenderness 
when acute articular rheumatism is not manifestly present. In well- 
marked cases the diagnostic points are the epiphyseal enlargement of 
the ends of the long bones, especially the wrists and the sternal ends 
of the ribs; the prow-shaped head; the deep, small chest; and the big 
belly. Delayed dentition and an anterior fontanel open long beyond 
the proper time are equally characteristic. If the disease has advanced 
still further, one often finds curvature of the bones of the legs and 
arms. 

Delay in learning to walk should also excite suspicion of the pres- 
ence of rickets. 

Differential Diagnosis. — From Pott's disease rhachitic spinal curves 
are sometimes not easily distinguished. Young children a few months 
old are not infrequently brought for examination on account of a prom- 
inence in the back and a great deal of crying in being lifted or handled. 
At the junction of the lumbar and dorsal regions a prominence may be 
present, involving several vertebrae, which may or may not be obliter- 
ated when the child lies on its face and is lifted by its feet from the 
table. Sometimes the constitutional evidences of rickets are so marked 
that the diagnosis is clear; Pott's disease, when it occurs in young chil- 
dren, begins often in this location and in this way. The writers have 
seen cases in which doubtful kyphoses of the same characteristics have 
been kept under observation and treatment, and one case has proved to 
be rhachitic, while another developed into clearly marked Pott's disease. 
Rhachitic kyphosis is more common than Pott's disease in children un- 
der eighteen months, and, although the presence of rickets does not 
rigidly exclude the possibility of Pott's disease, yet when the general 
signs of rickets are present, it is safe to assume that in most cases the 
kyphosis will disappear under treatment. In doubtful cases time alone 
will clear up the question. 

Prognosis. — When the disease is left to itself it generally runs its 
course, and after a decided degree of bony deformity has occurred the 
process of bone softening is spontaneously arrested, and the bones 
harden in their deformed condition. 

Spontaneous arrest of the disease may take place at any stage with- 
out treatment, but, as a rule, in severe cases not before a serious degree 
of bony deformity has been produced. When the disease is treated 
efficiently, the prognosis as to life is always favorable, unless some seri- 
ous complication is present, and the disease is, as a rule, easily amenable 
to treatment. 



280 ORTHOPEDIC SURGERY. 

The kyphosis above alluded to disappears or diminishes with the 
growth of the child. Lateral curves, however, are more permanent. 
As a rule the bony deformities, such as epiphyseal enlargement, dimin- 
ish with growth, but remain through life to a certain degree. 

Treatment. — The treatment of rickets consists, first, in the proper 
feeding of the child! For what this food should be the reader is re- 
ferred to works on the diseases of children. In addition to this diet, it 
is desirable to give to rhachitic children of over six months meat juice 
or raw beef in small quantities and orange or lemon juice. Drug treat- 
ment is manifestly secondary in importance to careful regulation of the 
diet and hygiene. A remedy much advocated in the treatment of rick- 
ets is phosphorus. It is given in doses of T -j-g- to T -^ of a grain three 
times a day. It may be given in the form of the officinal phosphorated 
oil mixed with olive or almond oil. The writers have seen but little 
benefit from its use, and believe that simple tonics accomplish as much 
as any drug. The syrup of the iodide of iron seems a useful prepara- 
tion. Cod-liver oil is of use. 

Hygiene and General Surroundings. — Rhachitic children should be 
bathed daily, preferably in salted water, and rubbed vigorously. Warm 
woollen clothing should be worn and they should go out daily. Espe- 
cial care should be taken to keep them in sunny, well-ventilated rooms; 
their meals should be regular, and they should be obliged to eat slowly. 
The bowels should be watched and kept regular, and every care should 
be paid to keeping the child's general condition as good as possible in 
every way. The seashore hospitals, now established in Italy, France, 
Germany, and America, provide, with proper nursing, air, and food, the 
best prophylactic against rickets. 

The discussion of the operative and mechanical treatment of rickets 
will be taken up under the head of knock-knee and bow-legs. 

OSTEOMALACIA. 

Osteomalacia is a process somewhat similar to rickets in causing 
softening of the bones. Although the pathological processes in the 
two diseases are distinct, there is a question whether the two diseases 
are not more closely allied than has been supposed. 1 

In osteomalacia there is absorption of the lime salts, beginning in 
the marrow of the bone and affecting first the spongiosa. The medulla 
becomes hyperaemic and there is an increase of lymphoid and fatty ele- 
ments. The medullary cavity extends at the expense of the cortical 
part, and the resistance of the bone is so impaired that it bends or 
breaks. The periosteum is likely to be thickened and vascular. There 
is some tendency to new bone formation, especially at the site of fract- 

1 Joachimsthal: Handb. der orth. Chir., 1904, i., p. 77.— Kassowitz : Wiener 
med. Woch., 1901. 38. — Morpurgo: Cent. f. allg. Path..xii.. 1902. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



281 



ures. The disease is most prevalent among the lower classes, and it 
affects certain localities more than others. Females are attacked more 
often than males. 

The disease may be divided roughly into the puerperal and the non- 
puerperal form. 

The former occurs during pregnancy and attacks the pelvis most 
often, extending perhaps to the spine and other parts later. The out- 
look for recovery is more favorable in this form. 

The non-puerperal form may attack children or adults of any age. 





FIG. 227. — Case of Osteomalacia in a Girl of 
Fifteen Years. Showing deformities of 
legs and arms. (C F. Painter.) 



FIG. 



—Skeleton in Osteomalacia. 
(Warren Museum.) 



Its etiology is unknown, and it begins most often in the lower ex- 
tremities or in the skull. The progress is slow and the outlook un- 
favorable. 

The symptoms consist of dull pain and perhaps tenderness in the 
affected parts, hyperesthesia of the skin, and discomfort in walking or 
sitting. This is followed or accompanied by yielding of the bones and 
fractures, complete or incomplete. 

Osteomalacia in children is seen at times, and its relation to 



282 



ORTHOPEDIC SURGERY. 



rickets is obscure. 1 Both conditions may evidently exist in the same 
patient. 2 

The treatment of the disease must be directed to the relief of the 
symptoms and must be conducted on general principles. 



CHONDRODYSTROPHIA FCETALIS. 

Chondodystrophia fcetalis. (achondroplasia — foetal rickets). 
Although this condition is described frequently under the name of 

fcetal rickets, it is essentially a different pathological process. 3 Clini- 
cally the children at birth seem to pre- 
sent the signs of a severe grade of rickets 
which has run its course. The head is 
large and the bridge of the nose depressed. 
There is beading of the ribs and perhaps 
flattening of the sides of the chest. The 
long bones of the extremities are short- 
ened and perhaps bowed and enlarged 
near the joints. 

The essential pathological process is, 
however, a disturbance of the normal 
process of ossification of the primary 
cartilage. The cartilage atrophies and 
the process of ossification takes place ab- 
normally early. The affection apparently 
begins between the third and sixth months 
of intrauterine life and has almost ceased 
at birth. It does not involve bones which 
exist only in cartilage until a late period 
of intrauterine life, and this accounts for 
its distribution. The medullary canal of 
the long bones is diminished in size and 
there is a periosteal overgrowth at the 
epiphyses simulating the real enlarge- 
ment occurring in rickets. 

In true chondodystrophia the bones 
will remain distorted, the joints will prob- 
ably be limited in their range of motion, 

and the general growth of the body retarded. The milder cases may 

reach adult life. 

1 Roos : " Schwere Knochen-Erkrank. im Kindesalter — Osteomalacic ? Rachi- 
tis ?" Zeitsch. f. klin. Med., lv., 1903. 

-Recklinghausen: Wien. med. Woch., 1898. — Joachimsthal : Handb. f. orth. 
Chir., 1904, i., p. 79. 

:i J. L. Morse: Arch, of Pediatrics, August, 1902 (with bibliography). 




FIG. 229.— Chondrodystrophia Foe 
talis, "Congenital Rickets." 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 283 

The treatment can only be palliative, and must consist of manipu- 
lation and massage of the restricted joints and the prevention of bow- 
ing of the spine when it is threatened by the use of a brace or by rest 
in the recumbent position. 

Congenital rickets is a name that may be applied to cases in which 
ordinary rickets obviously exists at birth, but not to those cases in which 
it has reached the severe grade just described. 

KNOCK-KNEE AND BOW-LEGS. 

The surgical interest in rickets is centered on the bony deformities 
which result from the disease and persist after the morbid process has 
ceased its activity. 

The curves of the bone are various, but those which are chiefly in- 
teresting to the orthopedic surgeon are those of the lower extremity, 
knock-knee and bow-legs. 

KNOCK-KNEE. 

Knock-kncc, or genn valgum,, is the name applied to an internal an- 
gular prominence of the knee, in which the bones of the leg form an 
abnormal lateral angle with the bones of the thigh, and this angle 
opens outward. 

This condition is also known in English as in-knee ; in Latin as genu 
introrsum ; in German as Knickbein, X-bein, Backerbein, Ziegenbein, 
Kniebohrer, Knieng, and Schemmelbein ; in French as genou cagneux, 
genou en dedans ; and in Italian as ginocchio torto all' indentro. 

Occurrence and Etiology. — The deformity is one of common occur- 
rence, but not so common as bow-legs. In 12,694 cases of orthopedic 
affections treated at the Children's Hospital, Boston, there were 1,807 
cases of bow-legs and 753 cases of knock-knee. Both deformities affect 
boys more often than girls. 

Knock-knee is a deformity which appears for the most part shortly 
after the children learn to walk ; it appears also between the ages of 
twelve and eighteen. Exceptional cases occur at any age. 

Knock-knee occurring in the first period named is almost always 
associated with general rickets, and is sometimes called genu valgum 
rhachiticum, to distinguish it from the form occurring at puberty, which 
is spoken of as genu valgum staticum or adolescentium. Many efforts 
have been made to identify this later form also with rickets, to consider 
it a local rhachitic process, a form of "latent rickets." The form of 
knock-knee occurring in adolescence especially affects persons whose 
occupation compels them to be most of the time in a standing position, 
and, as a rule, those affected are individuals of feeble physique. 

Other cases of knock-knee are produced as a late result of muscu- 



284 



ORTHOPEDIC SURGERY. 



lar paralysis. Fractures about the joint and destructive ostitis of the 
knee are also causes of knock -knee in their late history. 

Mechanical Production of Knock-knee. — While the chief cause of the 
deformity seems to be a static one, due to the superimposed body 
weight, pressure from faulty position and abnormal strain, as has been 
shown by Dane, may be a factor in the production of bony curves. 
Other causes are to be found in peculiar gait, distributing the weight 
and strain in an unusual manner. 

The normally formed human being in the upright position stands 
with a certain amount of knock-knee. The femurs form an angle of 
1 5° with each other and sometimes more, and, as a result of this oblique 
direction, the inner condyle of the femur must 
be longer than the outer. When a normally 
formed person stands' erect with the heels to- 
gether, if a plumb line be dropped from the head 
of the femur it will be seen to fall outside of the 
centre of the knee-joint ; and this will happen to 
a greater extent in the female than in the male. 

It is therefore evident that the external con- 
dyle of the femur and the corresponding facet of 
the tibia transmit more body weight than do the 
corresponding internal articular surfaces, because 
the centre of gravity lies outside of the centre 
of the joint. 

To maintain an erect position with the feet 
together requires muscular action. If the stand- 
ing position is to be maintained for a iong 
time, or for a short time in the case of children or feebly developed 
adults, the instinctive disposition is to substitute ligamentous for mus- 
cular support. This can be accomplished by keeping the knee extended 
and separating and everting the feet. It is the attitude assumed by 
children learning to walk and by tired adults. This attitude is often 
spoken of as " the attitude of rest." 

From this position more weight than before is transmitted through 
the external condyle and less through the internal one. If angular 
deformity takes place finally, all the weight is transmitted through the 
external condyle. 

Two results may follow from this : stretching of the internal lateral 
ligament and atrophy of the external condyle. 

The stretching of ligaments when subject to undue tension is too 
familiar a pathological process to require comment. The atrophy and 
retarded growth of bone, and especially rhachitic bone which is sub- 
jected to pressure and strain, are well known. 1 

1 Lane: Guy's Hosp. Rep., vol. xxviii. 




FlG. 230. — Axis of a nor- 
mal leg, and of one 
Affected with Knock- 
knee. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



285 



Flat-foot ordinarily coexists. Sometimes it must stand in a causa- 
tive relation to knock-knee ; sometimes it is more the result than the 
cause, but commonly they are both the results of the same faulty atti- 
tude, assumed as a result of muscular fatigue and weakness. Flat-foot 
is more easily produced than knock-knee, and is more common. 

It is proper to recognize the class of cases when the femur is appar- 





FlG. 231.— Slight Knock-knee. 



Fig. 2^2. — Moderate Knock-knee. 



ently normal, but the articulating surfaces on the head of the tibia are 
oblique. 

In still a third class of cases the deformity is due not so much to 
primary joint obliquity as to a bend in the diaphysis of the femur or the 
tibia just above or just below the joint. 1 

There are, then, three bony deformities likely to be found in cases 
of knock-knee, viz.: 

1 Arch. f. klin. Chir., 1879. xxiii. 



286 



ORTHOPEDIC SURGERY. 



(a) Difference in the size of the condyles of the femur. 

(b) Inequality in the articular facets of the tibia. 

(<f) Bending of the diaphyses of the bones above or below the 
joint. 

In severe cases the tibia is found to be rotated outward. 
The internal ligaments are hypertrophied, and the muscles and ten- 
dons on the inner aspect of the leg are, of course, stretched. The pa- 
tella lies farther outside than it should do. In some it may be seen 

that the outward rotation of the 
tibia is so marked that a sort of 
compensatory inversion of the 
feet has been acquired almost to 
the condition of varus to aid in 
keeping balanced. 





Fig. 



-Severe Knock-knee due to Ri 
ets. Seen from behind. 



FIG. 234.— Slight Knock-knee Resulting 
from Tuberculous Disease of the Left 
Knee. Now cured. 



Symptoms. — Subjective symptoms in knock-knee are almost always 
absent. Children and adults tire more easily than they should when 
they have knock-knee, and sometimes pain and sensitiveness are com- 
plained of over the internal lateral ligament of the knee ; as a rule those 
with knock-knee are clumsy and have a poor sense of balance. In 
young children with knock-knee and active rickets locomotion is gen- 
erally difficult, while in adult cases there is less difficulty in walking, 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 287 

even in severe cases, than would be expected from the degree of the 
deformity. 

In the standing position it is noticed that the knees are unduly 
prominent on the inside aspect of the leg, and that the tibiae diverge so 
that the feet are perhaps only a few inches apart, or, again, in severe 
cases, a considerable distance. In cases in which the angular deform- 
ity is very great, the patients find the easiest position for standing is 
with one knee- behind the other, so that in this way the feet may be 
brought together. 

If the child stands with the feet together one knee is generally a 
little hyperextended and the other slightly flexed, so that they appar- 
ently come together. 

The gait of a patient with double knock-knee is distinctive. The 
gait is a rolling one, consisting of a series of slight lurches, which are, 
however, not nearly so marked as in bow-legs or congenital dislocation 
of the hip ; while what is particularly noticeable is the outward throw 
of the leg when it is being brought forward. 

The gait is, moreover, slightly modified by the fact that in severe 
cases the thighs and consequently the knees are slightly flexed. 
"Toeing in " is common, even in the slighter grades. 

When the deformity is unilateral the limp is less marked. Lateral 
curvature is sometimes induced by the unilateral deformity. 

On manipulation, the knee-joint is often movable in a lateral plane 
through an arc of several degrees. In these cases the deformity is, of 
course, increased when weight is put upon the affected leg, so that in 
walking and standing it reaches its maximum. 

The angular deformity disappears when the knee is flexed to a right 
angle, except in cases in which the chief deformity is in the tibia. But 
if the knee be flexed while the hip-joint is still extended, the deformity 
does not entirely disappear, though it is very much diminished. 

The practical point is, that as the deformity is most severe when 
the leg is in the extended position, all mechanical treatment applied 
to the correction of knock-knee must be to the fully extended leg. 
When the leg is fully flexed the inequality in the length of the condyles 
is most evident, as seen in outline from the anterior surface of the 
thigh. This may. be registered by shaping a lead strip to the lower sur- 
face of the femur when the knee is fully flexed, and drawing an outline 
on paper from the lead strip, which should be stiff enough to keep its 
shape. 

Occasionally one sees a combination of knock-knee and bow-legs in 
the same subject. 

Loose Knees. — In young children beginning to walk, who have 
grown rapidly or who have perhaps the mildest degree of rickets, there 
is often developed a laxity of the knee-joint which may require treat- 



288 



ORTHOPEDIC SURGERY. 



ment. On account of the mechanical conditions explained above they 
stand with the knees prominent inward, but the deformity disappears 
on lying down and no overgrowth of the internal condyle is to be found. 
The knees can easily be hyperextended and are abnormally movable 
laterally. Such children are unsteady on their feet and the apparent 
knock-knee is noticed. The treatment consists of the measures to be 
described in speaking of the mildest cases of knock-knee. 





FIG. 235.— Bow-leg of Right Leg, 
Knock-knee and Flat-foot on 
Left. 



FIG. 236. —Hyperextended Position of 
the Knees, Frequently Seen in Con- 
nection with Knock-knee. 



Measurement of the Deformity '.—The simplest and most reliable 
method of registration is to have the patient sit upon a sheet of brown 
paper with the legs extended and the feet pointing upward ; and then, 
with a pencil held perpendicularly to the paper, to trace the outline of 
the legs. No other method can give so accurate an idea of the degree 
and character of the deformity present, or can afford so delicate a means 
of watching and recording the progress of the case. 

Diagnosis. — The diagnostic points which mark the affection known 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



2S9 



as knock-knee are an inward angular deformity at the knee which disap- 
pears on flexion of the leg upon the thigh. There is also in the latter 
position to be noted a relative prominence of the internal condyle of the 
femur in nearly all cases. 

In children the large proportion of all cases are rhachitic and static, 
while in adults the purely static cause must be assigned. It is not, in 
general, justifiable to assume rickets as the cause of knock-knee in 
cases in which there are no distinctive signs of rickets. 

Paralytic knock-knee occurs only in severe grades of paralysis. Its 

diagnosis is evident from the 

wasted and contracted condition 
of the paralyzed limb. 

Knock-knee from destructive 
disease of the knee-joint is a re- 
sult of severe tumor albus and 
not of the lighter grades. 

Traumatic knock-knee is of 
two kinds: (a) Resulting from 
osteotomy for genu varum and 
overcorrection of the deformity ; 
(b) resulting from fractures of 
the condyles of the femur or of 
the articular facets of the tibia, 
which are liable to cause lateral 
malposition of the knee. 

The ,t'-ray is of use in defin- 
ing the chief location of the de- 
formity when necessary. 

Prognosis. — In severe cases 
it is evident that so much harm 
has been done already, and the 
bones have come into such faulty 
apposition, that spontaneous improvement is not to be expected. Chil- 
dren with a slight degree of knock-knee which is not progressive will 
probably outgrow it without any treatment if in vigorous health. But 
if the deformity is moderate or severe, the chances are strong that 
the affection will remain stationary or more probably will become worse 
as time goes on, unless active treatment is begun. 

Treatment. — The treatment of knock-knee falls into three divisions : 
I. Expectant. II. Mechanical. III. Operative. 

I. The expectant method of treatment relies upon nature's efforts 
to repair the deformity ; efforts which are aided on the part of the sur- 
geon by keeping the child off of its feet to a greater or less extent, and 
by constitutional treatment and by massage and corrective manipula- 
19 




FlG. 237. — Case of Knock-knee, Showing also 
the Tracings of the Legs at an Interval of 
Four Years with no Treatment. 



290 ORTHOPEDIC SURGERY. 

tion. In mild cases there is a tendency to outgrow the deformity, but 
this tendency is at a great disadvantage mechanically, nor is it a safe 
proceeding to wait for this spontaneous cure in any marked case of 
knock-knee. The difficult question in the whole matter is to decide 
which cases can be left to themselves — a question which cannot be an- 
swered categorically. 

An argument for the spontaneous outgrowth of knock-knee is found 
in the rarity of adult cases which present themselves at clinics. 

When the expectant method is chosen in rhachitic knock-knee, the 
child should at once be put upon the constitutional treatment for rick- 
ets. If the knock-knee is merely the outcome of a feeble general con- 
dition, the patient should be most carefully looked after in the matter 




FIG. 238.— Manipulation in the Treatment of Knock-knee. 

of hygiene, and tonic treatment and gymnastics should be given, the 
aim of which should be to strengthen the leg muscles. As much as 
possible the patient should be kept off of the feet, and a change to 
country air is capable of effecting great local improvement in feeble 
children. 

The legs should be rubbed and manipulated each night. The rub- 
bing should be the same as that described under infantile paralysis, and 
the manipulation, in cases of knock-knee, should be directed to the 
gentle correction of the deformity by repeated mild manual pressure. 
With one hand the manipulator presses the knee outward, while with 
the other he presses the lower part of the tibia inward. Even with a 
very slight degree of force a certain yielding can be felt in the direction 
of improvement, and then the pressure should be relaxed and the limb 
allowed to resume its first position. This manipulation should be re- 
peated many times, continuing each pressure only a few seconds. Nor 
should it ever be done forcibly or long enough to make the child cry. 
This manipulation faithfully carried out is an important adjuvant, not 
only of expectant but of mechanical treatment. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



291 



In no case should expectant treatment be considered when the 
child is not under sufficiently close observation to be seen every few 
weeks, and to have tracings taken to determine whether the deformity 
is improving or is stationary. 

It is advisable in early knock-knee to raise the inner border of the 
foot in order to bring the line of weight bearing at the knee as far out- 
side as possible. For this purpose felt pads shaped to support the arch 
of the foot are of use, or the inner border of the sole and heel of the 




FIG. 239. —Knock-knee, Irons Applied. 
Front view. 



FIG. 



-Knock-knee, Irons Applied. Side 
view. 



shoes may be made one-eighth or one-fourth inch thicker than the outer 
border in order to accomplish the same object. 

II. Mechanical Treatment. — Treatment by apparatus aims at the 
gradual correction of the deformity, commonly by making counter- 
pressure against the internal condyle to prevent the further giving way 
of the knee and to pull it outward to a fixed point furnished by an out- 
side upright. Upon this principle all modern apparatus is constructed. 

In children in whom the change known as eburnation has succeeded 
rickets, the bones are so hard and unyielding that it is almost hopeless, 
by means of such mild traction as can be exerted, to pull the knee back 
into place. In general terms, it is not probable that mechanical treat- 



292 



ORTHOPEDIC SURGERY 



ment will be of use after the age of four years has been reached except 
in slight cases ; nor is osteotomy or osteoclasis likely to be considered 
before that. time. Under this age in moderate degrees of deformity the 





Fig. 241. Fig. 242. 

FIGS. 241 and 242.— Knock-knee. Mechanical 
treatment for one and one-half vears. 




Fig. 244. 
Knock-knee Cured in 
Three Years by the use of Simple Out- 
side Upright. A good average result. 



Fig. 243. 
Figs. 243 and 244. 



outlook is good with mechanical treatment, and the younger the patient 

the better the outlook. 

Former orthopedic methods are exemplified by methods of recum- 
bency, a method which has practically be- 
come obsolete. 

In the ambulatory treatment of the 
affection, a form which has been in use for 
some years at the Children's Hospital 
(Chapter XXL, 18) has proved itself effi- 
cient in practical use. It is a light steel 
rod attached below to a steel sole plate 
and jointed at the ankle. It runs up the 
outside of the leg as far as the trochanter, 
and then the rod is bent backward and up- 
ward, to lie against the upper part of the 
buttock and to serve as an arm by which 
the legs can be everted if the child toes in 
in walking. The knee is drawn upon by 
a square leather pad, pulling from the 
shaft opposite the knee. 
There is no advantage in carrying the outside uprights to a rigid 

waist band, as is done sometimes. Braces are worn until the line of 

the leg becomes practically normal. 

III. Operative Treatment. — The modern operative treatment of 

knock-knee is comprised under the simple operations of osteotomy and 

osteoclasis. 

Osteotomy. — The operation consists in the division of part of the 





FiG. 245.— Line of Cutting in Oste- 
otomy for Knock-knee. The pict- 
ure on the left is the ordinary 
Macewen operation. The one on 
the right shows the removal of 
a wedge of bone required only 
in the severest cases. 



RICKETS, KNOCK-KNEE, AND BOW- LEGS. 



293 



bone by the chisel, and the completion of the procedure by fracture of 
the partly divided bone. 

The operation is performed as follows : The patient's leg is rendered 
aseptic ; the patient lies on his side with the leg extended, the outer 
side of the knee resting on a sand-bag. The skin and underlying tis- 
sues may be divided with a knife over the point of division of the bone, 
or, what is more simple, the chisel is driven through the sound skin 
into the bone without any incision. This diminishes the bleeding and 




FlG. 246. — Proper Position for the Hand and Osteotome in Performing Osteotomy. 



simplifies the operation. The use of an Esmarch bandage is unneces- 
sary. 

The point selected for fracture is the point at which the chisel is to 
be inserted. This should be as near to the joint as is practicable with- 
out injury to the joint. The chisel can be inserted on the inner or outer 
side of the femur. There are no especial advantages of either side for 
the point of entrance of the chisel, which is determined by the custom 
of the surgeon. The place most commonly selected is that recom- 
mended by Macewen, 1 on the inner side, a short distance above the tu- 
bercle of the adductor tendon. The distance varies with the size of the 
patient. In children it should be but little above ; in older cases, where 
the width of the bone is to be considered, a point one-half inch above 

1 Brit. Med. Journ.. June 30th. 1888. p. 1377. — Lancet. April 21st. 1889. 



2 9 4 



ORTHOPEDIC SURGERY. 



the tubercle is the point of election. The osteotome is driven into the 
bone with the blade at right angles to the long axis of the femur, and 
by successive blows with the mallet the operator cuts nearly through 
the whole thickness of the bone. The osteotome is likely to become 
wedged very firmly unless the precaution is taken to move the handle 
of the chisel laterally after each blow. In this way alone can one cut 
from the front to the back of the bone, for driving the chisel straight 
through in one line accomplishes but little. When the chisel has dis- 





FiG. 247.— Moderate Knock- knee Before 
Operation. 



Fig. 248. — Same Case After Macewen Oste- 
otomy. 



appeared to a depth indicating that three-quarters of the bone has been 
divided, it should be withdrawn and an attempt made to fracture the 
thigh by gentle bending. If this cannot be done, the osteotome should 
cut further, for the common mistake is a failure to divide the anterior 
and posterior borders of the femur. 

Some skill is required in the use of the osteotome, which is made to 
serve not only as an instrument for dividing the bone, but as a probe 
which enables the surgeon to determine what portion of the structure 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 295 

he is dividing. The bone being in its different parts of different hard- 
ness, the resistance varies, and the localization of the part cut is not 
difficult. As little injury as is possible should be done to the bone, and 
little is inflicted if the osteotome divide the outer cortex for the width 
of an inch on the side entered and undermine the cortex of the re- 
maining side, cutting through the spongy portion. The insertion of 
different sized osteotomes is not necessary. The osteotome should be 
held firmly and its direction carefully attended to by the surgeon. 

When the bone has broken, unnecessary manipulation should be 
avoided, but the limb should be put in a corrected position after having 
been overcorrected, and, after an aseptic dressing has been applied, a 
plaster-of-Paris bandage should be put on to hold the leg in a corrected 
position. But little pain follows the operation. No change of dressing 
is needed; the plaster may be removed in three or four weeks, another 
reapplied, and in six weeks or more the patient allowed to stand on the 
limbs. 

In correcting the deformity it is manifest that in one place a gap is 
left to be healed by blood clot, and in another place the divided frag- 
ments will be pressed firmly together. As the periosteum is but little 
damaged, firm union takes place, as has been shown clinically in a 
large number of cases and by pathological specimens of cases dying a 
year or more after the operation. The operation, when properly per- 
formed, is devoid of danger, and non-union need not be anticipated in 
cases suitable for operation. 

Sometimes, when the deformity lies chiefly in the head of the tibia, 
the operation of osteotomy might be performed there either alone or in 
connection with femoral osteotomy. The removal of a wedge of bone is 
rarely necessary from either the femur or tibia in cases of knock-knee. 

Much care is needed in the application of the retaining plaster 
bandage. After the wound has been properly protected by aseptic 
dressings, the limb should be carefully covered with cotton, not only to 
allow for shrinking of the tissues, but to prevent undue pressure on any 
projecting points. 

If the limb has been properly corrected, which is essential to the 
success of the operation, the application of the bandage differs in no 
way from that employed in the treatment of ordinary fractures. The 
danger of sloughing under the plaster is not great, but if the surgeon 
desires to examine the bone a window can be cut in the plaster. The 
bandage should not be removed or the corrected position interfered 
with until union takes place. 

Osteoclasis. — The forcible fracture of bone by instrumental or man- 
ual means in knock-knee is decidedly inferior to osteotomy, inasmuch 
as it lacks the precision of that method ; more splintering occurs, and 
rupture of the external ligaments and epiphyseal separation are apt to 



296 



ORTHOPEDIC SURGERY. 



occur, as in redressement force. 1 It is therefore better to limit the 
use of osteoclasis to the correction of bow-legs, where the instrumental 
or manual force can be applied to the shaft of a long bone. 

BOW-LEGS. 

Bow-legs is the name applied to the opposite deformity to knock- 
knee, which is an outward angular deformity of the knee, or a general 




Fig. 249.— Child Sitting Turk Fashion, Pro- 
ducing, at Junction of Lower and Mid- 
dle Thirds of Legs, Anterior and Lateral 
Bowing. (Children's Hospital Report.) 



Fig. 250.— Child with Bow-legs in Ordinary 
Sitting Position, Showing Fitting of One 
Leg to the Other. (Children's Hospital 
Report.) 



outward bowing of the legs, so that when the patient stands erect with 
the heels together the knees are a greater or less distance apart. 

The condition is also known as genu varum, genu extrorsum, out- 
knee, bowed legs, or bandy legs. In German one speaks of it as Sabel- 
bein, Sichelbein, O-bein, and in French as Genou en dehors. 

It is single or double, generally the latter, and may exceptionally 
exist in one leg when knock-knee is present in the other. 
'Codiilla: Zeitsch. f. orth. Chir., Bd. xi. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



297 



Occurrence. — The deformity is almost always the result of an out- 
ward yielding of the long bones of the leg, especially of the tibia. At 
times, however, it is clearly due to an obliquity at the knee-joint, where 
the external condyle appears the larger of the two. 

The anatomical changes found are those of rickets. The bending 
of the bones is in most cases, like the other deformities of rickets, a 
simple yielding, without fracture or destruction of bone tissue. 

Causation. ^Bow-legs is essentially a rhachitic deformity in chil- 
dren, and true bow-legs can occur only in a child whose bones are soft 
enough to bend easily. It occurs in the first three or four years of life, 
and ordinarily in connection with general rickets; sometimes, however, 
other rhachitic manifestations are absent ; but the yielding of the bones 
in a child of this age must of itself be accounted sufficient evidence of 
rickets. 

Bow-legs of a marked type are seen in children who are too young 
ever to have borne their weight upon their legs. To account for this, 
one must assume a lateral press- 
ure from carrying and from / 
the sitting position, along with 
the possibility of some distor- 
tion from tonic muscular pull. 
Early walking, so much talked 
about as a cause of bow-legs, 
is not to be accounted a factor 
of any importance in their pro- 
duction unless rickets in some 
degree is present. 

Why the bones should bend 
outward as they do is a question which is by no means settled. 

The child with rickets stands with thighs flexed and the lumbar 
spine arched forward; once given this condition, it is easy to see how 
bow-legs arise. As the thighs flex the knees are separated and the 
femurs rotate outward on their own axes; as a result of this the line of 
gravity, instead of falling outside of the knee-joint, as we have seen was 
the case in the normal erect position, falls inside of it ; and any yielding 
of the bones, of course, must take place in the outward direction. With 
the yielding of the bones the line of the legs falls farther and farther 
outside of the line of gravity, and the body weight continually acquires 
better leverage to bend the bones. 

Ante? ioi' curvature of the thigh and the leg bones is manifestly the 
result of body weight coming upon a flexed limb, conjoined perhaps to 
the action of the most powerful muscles in the body (the flexor muscles 
of the thigh) pulling in the same direction. 

Symptoms are absent, except, of course, those of rickets. But the 





Fig. 251. 
FlG. 251. — Bow-legs, Gradual 

the Whole Leg. 
FIG. 252.— Bow-legs, Curve mostly in Tibia. 



Fig. 252. 
Curve Involving 



298 ORTHOPEDIC SURGERY. 

deformity is plainly evident, and even in the milder cases the gait is 
modified in a characteristic way. The child walks with a distinct wad- 
dle and generally with the feet wide apart and a tendency to invert the 
toes. The gait in bad cases bears a resemblance to the waddling gait 
of double congenital dislocation of the hips. The line of the leg lies so 
much outside of the line of the centre of gravity that in bearing weight 





Fig. 253.— Standing- Position of Child with 
Moderate Bow-Legs. 



FlG. 254.— Curve Involving Whole Leg. 



on the left leg, for instance, the body must be thrown decidedly over to 
the left to bring it over its line of support ; it is in a measure the re- 
verse of the gait in knock-knee. This lurching is inevitable with each 
step, and, other things being equal, is in a degree proportionate to the 
amount of curve present. 

The deformity is almost always more conspicuous in the standing 
position, both because these children stand with the legs so far apart 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



299 



and because the knee-joints generally yield somewhat in a lateral direc- 
tion when the body weight is superimposed. 

The curve is most often a gradual and uniform bowing of the femur 
and tibia, so that with the feet together the outline of the legs forms an 
oval which in severe cases approaches a circle. A second class of 
cases presents a bowing chiefly in the lower third of the tibia which is 
more angular in character, and the femurs are practically normal ; a 
third class presents, either alone or in conjunction with the other de- 
formities, a bowing forward of the tibia and sometimes of the femur 
also. These are the three common types of the deformity. At times 




Fig. 255.— Severe Anterior Bow-leg, Seen from the Front and Side. (H. L. Burrell.) 

the deformity lies chiefly in the knee-joint and the bones are compara- 
tively straight. 

Occasionally the condition of knock-knee and bow-leg existing in 
the same leg is seen. 

An inward rotation of the lower part of the tibia exists in bow-legs 
which causes " toeing in " in walking. This is apparently a part of the 
process of side bending, as a three-cornered weight-bearing body like the 
tibia, in bending to the side, finds less resistance in bending and twist- 
ing than it does in bending alone. 

Diagnosis. — The condition of bow-legs is evident on inspection. 
Macewen's definition applied to this deformity would be, that it was a 
condition in which a line drawn from the head of the femur to the mid- 
dle of the ankle-joint would fall inside of the centre of the knee-joint. 



300 



ORTHOPEDIC SURGERY. 



It is often difficult to determine how much of the deformity lies in 
the tibia and how much in the femur. If the legs are crossed until the 

insides of the knees are together when 
the child is in a sitting position, it will 
be seen whether the femurs include an 
oval space between them or are parallel 
to each other. 

Prognosis. — The prognosis in out- 
ward bow-legs is favorable ; in anterior 
bow-legs, less favorable under expectant 
or mechanical treatment. The prospect 
of spontaneous outgrowth of the de- 
formity is better than in knock-knee, 
and in young children rational mechan- 
ical treatment offers almost sure relief. 
The prognosis of bow-legs, when un- 
treated, will be considered more in de- 
tail in speaking of the treatment by 
expectancy. Operative treatment can 
ameliorate almost any condition of de- 
formity and often entirely rectify it. 

When the deformity is extreme or 
the bones are eburnated, it is not, of 
course, likely that the child will outgrow 
the bow-legs. 

Treatment. — The treatment of bow- 
legs, like that of knock-knee, is to be 
considered under three heads: I. expec- 
tant, II. mechanical, III. operative. 

I. The expectant treatment is suited 
to a large percentage of cases of the 
deformity, and its range of applicability 
is wider than in knock- knee. The me- 
chanical conditions are not so much in favor of the increase of the de- 
formity as in knock-knee, and the tendency in slight cases is toward 
rectification in the course of growth. In general, when the curve is 
uniform, involving femur and tibia alike, the chances are more favor- 
able for spontaneous cure than if the deformity is localized in the tibia 
and more angular. 

During expectant treatment the general condition should be most 
carefully attended to and rickets treated from the first. The child 
should be encouraged to be off of his feet as much as possible, and the 
legs should be massaged and manipulated each night, being gently bent 
toward a straight direction. 




FIG. 256.— Anterior Bow-legs. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



301 



In all cases tracings should be taken at least once each month, to 
determine if the deformity remains stationary or is improving, and 
if after two or three months no improvement is evident, mechanical 
treatment should be 
begun. 

II. Mechanical treat- 
ment is based upon the 
principle of drawing the 
knee inward to a rod 
which has counter- 
points for sustaining 
outward pressure at the 
upper part of the thigh 
and at the ankle. Here, 
as in knock-knee, trac- 
tion from a rigid rod is 
more definite and more 
satisfactory than from 
an elastic one. The 
form of apparatus used 
is of little consequence 
so long as it answers 
the indications and 
holds the knee extended 
(Chapter XXI, 21). 
It is no longer custom- 
ary to treat these cases 
by recumbency. 

The apparatus 
shown (Chapter XXI, 19) is the one generally in use at the Chil- 
dren's Hospital in Boston, and is serviceable. It consists of a steel 
upright, which is attached below to the sole plate of the shoe. It runs 
up nearly to the origin of the adductor muscles, but it must fall a little 

short of them or it will ex- 
coriate the skin in walking. 
The upright is then bent for- 
ward and upward, and curved 
to fit into the groin and come 
up as far as the posterior part 
of the dorsum of the ilium. 
In this way a lever is provided 
_ ^ ^ with which to evert the feet 

Fig. 258. Fig. 259. Fig. 260. 

_ „ «,-*■-"*», r, t0 an Y extent by altering the 

FIGS. 258, 259, and 260.— Case of Bow-leg's. Prog- J J & 

ress in three years under expectant treatment. CUrve of these amiS and Strap- 




FlG. 257. -Bow-legs Affecting Chiefly Bones of Lower Leg. 






302 



ORTHOPEDIC SURGERY. 



ping them together behind. Pads for the outside of the legs are made 
of leather and buckled by two or three straps to the upright, opposite 
the greatest convexity of the curve. 

Anterior tibial curves are not susceptible of improvement or cure 
by mechanical treatment except in slight cases in which the bones are 
soft. In these cases it is useful to apply to the foot (Chapter XXL, 20) 

a modification of the brace de- 
scribed above (Chapter XXL, 19). 
The mechanical treatment of 
bow-legs should be advised in 
cases in which the deformity is 
severe or sufficiently obstinate to 
make it doubtful whether spon- 
taneous outgrowth of the deform- 
ity will occur, because braces do 
no harm and do not retard spon- 
taneous improvement. After the 
age of three or four it is not gen- 
erally worth while to begin me- 
chanical treatment. 

In the case of babies the ex- 
pectant plan of treatment is the 
one to be followed at first. 

III. Operative Treatment. — Os- 
teoclasis.— In the case of bones 
still soft or in very young chil- 
dren, if it is desired to operate at 
that stage, manual fracture has a 

FIG. 261. — Bow-leg. Brace Applied. , • ,i , • . , , 

place m the operative treatment, 
but even then manual fracture presents no advantage over the osteo- 
clasts. 

Mechanical fracture is made feasible by the use of osteoclasts, of 
which the one of Rizzoli is the simplest. The appliance is easily under- 
stood from the accompanying illustration. The instrument is made of 
heavy steel, and the rings and the screw pad all slide on the bar so as 
to be adjustable to any length of leg. The parts of the apparatus 
which come in contact with the leg are padded so that the edges shall 
not cut. The instrument is applied to the bared limb, the rings being 
adjusted as far as is possible from the point at which fracture is desired. 
In placing the rings of the osteoclast on the limb, care should be taken 
not to put them too near to the joints of the ankle or knee, as the epiph- 
yses might be separated by carelessness. The screw is to be adjust- 
ed so as to press at the point of election for fracture, which is at the 
point of the greatest convexity of the curve. Pressure is increased until 




RICKETS, KNOCK-KNEE, AND BOW-LEGS. 



303 



fracture of the bones takes place. The fibula generally breaks first, 
the tibia shortly afterward on continuing the screw pressure. The 
fracture of the bones is evidenced by a loud snap which can be heard 
anywhere in the room. 

The bone will usually be found to bend before fracture occurs. If 
the instrument is well padded there will be no clanger of injury of the 
skin from the temporary pressure necessary for fracture, although the 
amount of this pressure may be very great. The skin will become 
blanched or congested, but after the removal of the osteoclast the color 
will be found normal, with but slight evidence of pressure. The fract- 
ure will be found to have taken place opposite to the screw-pad plate. 

An excellent osteoclast, devised by Dr. R. T. Taylor, of Baltimore, 
has the advantage of working more rapidly. It is, however, somewhat 
more elaborate than the Rizzoli and not so easily carried about. 

After the bone has been broken, the osteoclast should be removed, 
the fragments placed with the hand in the desired position, sheet wad- 
ding carefully placed around the leg, and the limb fixed in a plaster 
bandage and held in a carefully corrected position. The bandage 




Fig. 262. — Rizzoli's Osteoclast. 



should reach from the toes to the hip, and the limb should be held in 
the corrected position until the plaster has hardened thoroughly. When 
there is a rotation of the tibia as well as a curvature, care should be 
taken to see that this also is remedied and that the limb is fixed in a 
normal position. 

Experience has shown that the procedure is ordinarily free from 
risk, and in properly selected cases the danger of non-union after fract- 
ure may be disregarded. The fracture is a transverse one and there 
is no danger of splintering the bone, A number of experiments upon 



304 ORTHOPEDIC SURGERY. 

the cadaver were made by the writers with reference to this point, and 
it was found that although splintering will take place in dry bone if 
subjected to fracture by an osteoclast, yet bone undried, as found in 
the dissecting-room, will break transversely ; the fracture takes place 
as a sharp linear fracture half-way through the bone. The part of the 
bone nearest the side of pressure breaks with an irregular line of 
fracture, as if torn. 

The amount of force required for the fracture of an adult bone 
is very great, so much so as to make osteotomy in most instances a 
preferable procedure. 

Osteoclasis near the joints is difficult, but in the shaft of the tibia 
the operation is an excellent one, yielding satisfactory results with but 
little discomfort to the patient. 

Cases should not be operated upon unless the bones are fairly 




Fig. 263. —Method of Applying Osteoclast. 

strong — that is, not if the rhachitic process has not been well arrested, 
as recurrence of the deformity may take place. 

As a rule, the operation should not be performed before the age of 
four. 

The limb should remain in a fixed bandage for four or five weeks, 
and no appliance is needed as an after-treatment. 

Osteotomy should be employed in place of osteoclasis in cases "of bow- 
legs (1) when the curvature is so near the joint that osteoclasis is not 
practicable ; (2) when the bone is so strong that osteoclasis is not feasible ; 
(3) when several curves exist in the same leg ; (4) when the curvature is 
anterior; (5) in cases of bow-leg in which the distortion is largely in 
the lower epiphysis of the femur ; (6) in cases in which it is desired to 
locate the fracture very accurately, as in badly united fractures of both 
bones of the leg with displacement. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 305 

Osteotomy for bow-legs is a similar operation to that for knock- 
knee; the division of bone is made wherever it appears most necessary, 
and no formal operation can be laid down. In young children the 
fibula need not be cut with the osteotome, but can be broken manu- 
ally. 

Anterior Bow-Legs. — In the treatment of anterior bow-legs, i.e., 
where the curve is forward and not to the side, the tibia may be broken 
by the osteoclast applied in the usual way, and after the fracture has 
been loosened by the hands the leg may be set straight. Tenotomy of 
the tendo Achillis aids this attempt and is generally necessary. Oste- 
otomy, however, as a rule is more satisfactory in these cases. In ante- 
riorly curved bow-leg in children, a linear osteotomy can be employed 
dividing the posterior two-thirds of the tibia and using the anterior por- 
tion as a hinge with the interlacing broken fibres and uninjured perios- 
teum to promote healing. The osteotome is inserted in the side of the 




FIG. 264.— The Lever Osteoclast of R. T. Taylor. 

tibia. By this procedure the shortening caused by removing a wedge 
is avoided. Considerable manipulation is necessary after the osteotomy 
to free the fragments from the shortened posterior tissue which is nec- 
essary to give a corrected position. The gap caused will, as in the oper- 
ation for knock-knee, heal by blood clot. In older cases a wedge- 
shaped excision may be necessary. 

After osteotomy it is not necessary to wire the fragments of bone 
together ; if they are placed in apposition and fixed, union can be ex- 
pected to take place. 

Ultimate Results of Osteotomy and Osteoclasis. — J. E. Goldthwaite 
traced out twenty -eight cases of knock-knee and bow-legs operated on 
in the Children's Hospital, not taking into account any case operated 
within a year and a half of the beginning of his investigation. There 
were eleven cases of Macewen's osteotomy for knock-knee and eleven 
of osteoclasis for bow-legs, while there were five cases of anterior bow- 
ing of the tibia treated by osteotomy. The average length of time 
after the operation was four years, and of these cases only one had re- 
20 



306 



ORTHOPEDIC SURGERY. 



lapsed. That was a colored boy, four and one-half years old, who pre- 
sented a condition of extreme rickets. He had both knock-knee and 
bow-legs, and osteoclasis and osteotomy were done and the knock-knee 
had recurred somewhat since operation. 

Cases will be met when several curves are present, and the judg- 





FlG. 265. — Bow-legs of Moderate Degree 
Before Operation. 



Fig. 266. 



-Same Case After Osteo- 
clasis. 



ment of the surgeon will be exercised in a choice of what bone is to be 
attacked and if more than one shall be operated upon at one time. 

In the hands of a surgeon skilled in these operations and working 
rapidly, several bones may be corrected at one sitting. The surgeon's 
purpose should be to correct those deformities which most interfere 
with normal gait, and leave others to the correction of growth. 

It may be said that the results in the treatment of these deformities 
in childhood are exceedingly satisfactory as a rule, the surgeon aiding 
nature, and nature completing the efforts of the surgeon, so that little 
or no trace of the previous deformity will remain in after-life. It is not 
advisable to operate in either bow-legs or knock-knee before the age of 
four years. 



RICKETS, KNOCK-KNEE, AND BOW-LEGS. 307 

RHACHITIC CURVES IN THE UPPER EXTREMITY. 

These rarely present themselves for treatment, and but little further 
need be said except that by means of osteotomy the curves of the upper 
extremity can be treated as readily as those of the lower. 

IMPROPERLY UNITED FRACTURES. 

The same method can be applied in the correction of improperly 
united fractures of the upper and lower extremities. In this class of 
affections, however, vicious callus may be present in such a way that 
more than linear osteotomy may be needed. The principles of treat- 
ment for the correction of these curves, in the main, are those consid- 
ered in the treatment of rhachitic curves. 

In deformity following badly united fractures, however, the employ- 
ment of a narrow osteotome applied freely at such points as may be 
necessary to weaken the callus will be found useful. 



CHAPTER X. 
COXA VARA AND COXA VAL'GA. 

Coxa vara and traumatic coxa vara. — Etiology. — Pathology. — Symptoms. — Diag- 
nosis. — Prognosis. — Treatment. — Coxa valga. 

It has been demonstrated by Dwight that the normal range of va- 
riation in the angle between the neck and the shaft of the femur is 
much greater than has been ordinarily supposed. When these varia- 
tions are slight no clinical symptoms follow, but disturbance of the 
function of the hip is likely to result when this angle is diminished be- 
yond a certain point. 

The name coxa vara is applied to the condition in which the 
neck of the femur is bent downward sufficiently to give rise to symp- 




FlG. 267.— Specimen of Severe Coxa Vara. (Robert Jones.) 

toms. This bending may reach such an extent that the neck forms 
with the shaft a right angle or less, instead of the normal angle of 120° 
to 140. 

ETIOLOGY. 

Coxa vara may be unilateral or bilateral, and affects males more 
often than females. It is, in general, an affection of growing bone, and 
is seen most often in adolescents, and next most frequently in children, 

•;oS 



COXA VARA AND COXA VALGA. 309 

although adults are not exempt. The more frequent affection of ado- 
lescents is explained because the disability is more noticed by them 
than by children, because the strain coming upon the growing femur is 




Fig. 268. — Radiograph of Same Specimen. (Robert Jones.) 

greater the larger the individual, and because the neck of the femur is 
relatively longer in them than in young children. 1 The affection may 
be congenital." 

PATHOLOGY. 

The shape of a growing bone is in general determined by the rela- 
tion between the strain coming upon it and the resistance of its struct- 
ure. If these relations are normal, the usual shape of the bone will be 
preserved ; if the resistance is diminished or the strain increased, mod- 
ifications in shape are likely to occur. 3 The causes of coxa vara are, 
therefore, to be sought in increased strain or diminished resistance in 
the neck of the femur. 

Coxa vara is to be found in connection with rickets, osteomalacia, 
acute osteomyelitis, and ostitis deformans. The changes resulting 
from the destructive processes of arthritis deformans and tuberculosis 

'Whitman: " Orth. Surgery," 2d edition. 

- Krebel : "Coxa Vara Congenita." Cent. f. Chir.. October 17th. 1S96. — Joa- 
chimsthal : Zeit. f. orth. Chir., xii.. 1 and 2, 52. 

3 Frieberg and Tavlor: " Wolff's Law." Orth. Trans., vol. xv. 



3io 



ORTHOPEDIC SURGERY 



of the hip may cause a changed relation between the head and shaft of 
the femur, simulating coxa vara. 

Coxa vara may exist in cases presenting no clinical or pathological 
evidence of any condition causing a softening of the bone. In certain 
marked cases the change in shape may be clearly seen without other 
evidence of disease. 

In addition to the downward displacement of the head and neck of 
the femur, there is generally also present a yielding of the neck in the 
horizontal plane. The most common bend of the neck is that with the 
convexity forward, so that the leg is rotated outward and the foot 
everted. In other cases, less commonly seen, the neck is bent with the 
convexity backward, and the foot and leg are inverted. In still other 
cases the depression of the head and neck in relation to the shaft may 
be directly downward without forward or backward bending. In these 




FlG. 269. — Specimen of Coxa Vara, no Clinical History. (Warren Museum.) 



cases neither eversion nor inversion will be marked. The changes may 
be most evident at the end of the neck of the femur nearest the tro- 
chanter or at the end nearest the epiphysis. In exceptional cases 
there may be bending of the upper part of the shaft of the femur. 



COXA VARA AND COXA VALGA. 



311 



Iraumatic Coxa Vara. 

(Fracture of the neck of the femur, epiphyseal disjunction, infraction 
of the neck of the femur, Schenkelhalsbruehe, etc.) 

Described under these various names is a changed relation between 
the head of the femur and its shaft, which may be classed with coxa 




FlG. 270.— Specimen of Severe Double Coxa Vara from an Adult Female (No. 3821 
in the Vienna Pathological Anatomical Museum). (Albert.) 

vara of non-traumatic origin. It is clearly traumatic in origin, follow- 
ing slight or severe accidents. It exists chiefly in children and is often 
overlooked. The pathological change consists most often of a displace- 
ment, partial or complete, of the epiphysis downward, and a consequent 
elevation of the trochanter in relation to the head of the bone. At other 
times the injury results in a real fracture or infraction of the neck of 
the femur, the junction of the epiphysis and shaft apparently escaping 
injury. 1 

x Hoifa: Zeitsch. f. orth. Chir., xi., 3. 52S (with bibliography).— Whitman : 
Am. Journ. Orth. Surgery, ii . 1. 



312 ORTHOPEDIC SURGERY. 

In some instances, while no evidence of trauma is clear, enough 
strain coming upon the epiphysis to modify the growth of the bone may 
have existed without giving rise to characteristic symptoms of fracture 




FlG. 271.— Coxa Vara and Bending Outward of the Upper Shaft of the Femur. (Albert.) 

or epiphyseal separation. In other cases a fracture of the neck of the 
femur in adolescents or children, sufficiently severe to necessitate 
thorough treatment by the usual methods, may be followed months after 
by yielding of the neck of the bone induced by the softening of the 
neck incident to callus formation. 



COXA VARA AXD COXA VALGA. 313 

SYMPTOMS. 

The early development of coxa vara is not likely to be accompanied 
by marked symptoms, the earliest signs noted being generally referred 
to the hip-joint, which is the seat of vague discomfort and slight irrita- 
bility and pain, and walking is avoided. The characteristic symptoms 
when the deformity is established are as follows : 

Shortening exists in unilateral cases and the trochanter is raised 
above Nelaton's line in both unilateral and bilateral cases. In children 




FlG. 272.— Sagittal Section of Coxa Vara, Showing Rearrangement of Trabecular to Com- 
pensate for Cross Strain. (Abbott.) 

the shortening may be slight. The trochanter in marked cases is more 
prominent than normal. 

Limitation of motion of the hip-joint is most marked in the direction 
of abduction, which is due not only to a shortening of the abductors, 
but to the pressure of the trochanter against the ilium when the leg 
is abducted. Joint irritability is generally present and may be severe 
enough to cause limitation of motion in other directions than abduction. 

Lameness and pain in the joint after exertion are fairly constant 
symptoms. If the affection is unilateral, a limp is noticeable; if bilate- 
ral, a waddling, restricted gait takes its place. 

When a backward twist of the trochanter exists, the foot will be 
everted and flexion of the thigh will be accompanied by eversion and 



3H 



ORTHOPEDIC SURGERY. 



abduction. When a forward twist is present, inversion of the foot is 
found. In severe eases the thighs may be crossed in front of the body 
in full flexion. 

Scoliosis may result in unilateral cases. In bilateral cases the dis- 
tance between the trochanters will be greater than normal. 

DIAGNOSIS. 



The recognition of 
chanter is hisrher than 



coxa vara is not difficult, 
normal, being above the 



The top of the tro- 
line drawn from the 



anterior superior spine of the ilium to the middle of the tuberosity of 

the ischium (Nelaton's line). Short- 
ening is present if the affection is 
unilateral. A femoral twist is recog- 
nized by determining on deep palpa- 
tion the direction of the trochanter rel- 
atively to the cross axis of the pelvis 
when the leg is straight and the patella 
faces directly forward. The trochan- 
Kpp . ■ ter points forward or backward, accord- 

II ing to the existing twist. In marked 
cases limitation in abduction is present, 
and in cases in which the hip is strained 
from inability to bear the strain inci- 
dent to locomotion, symptoms of joint 
irritation {i.e., pain and slight stiffness 
on passive motion) may be present. 
The diagnosis can be aided by a 
skiagram. 

Cases of coxa vara have been re- 
garded as suffering from hip disease 
and from congenital dislocation of the 
hip. Such mistakes can be avoided 
by a thorough examination of the case. 
In cases of hip disease of long duration 
the joint stiffness is greater than is 
seen in coxa vara. The stiffness af- 
fects all motions, and not chiefly ab- 
duction, and the trochanter is not elevated above Nelaton's line, ex- 
cept after considerable bony destruction, which will be accompanied 
by deep thickening about the joint and by marked muscular spasm. 
In congenital dislocation on deep palpation the head will be discovered 
outside of the acetabulum. On rotating the limb in congenital dis- 
location of the hip, the excursion of the head will be greater than that 




Fig. 273.— Traumatic Coxa Vara of Right 
Leg, from an Accident Occurring when 
Patient was Four Years Old. (Hoffa. ) 



COXA VARA AND COXA VALGA. 



315 



of the trochanter, the reverse being true in coxa vara. In coxa vara 
the distance between the trochanters is wider than normal, but this is 




Fig. 274.— Outline of Depressed Neck of Femur in Muller's Specimen. Contrasted with 
normal (in dotted line). (Whitman.) 



not the case in congenital dislocation of the hip. In coxa vara, if the 
patient stands upon the affected limb and raises the other from the 




Fig. 275.— Cross Section of Pelvis and Deformed Femur. A scheme to show the effect of 
the deformity in limited abduction. Dotted outline shows the normal relation. (Whitman.) 



316 



ORTHOPEDIC SURGERY. 



floor, the cross axis of the pelvis is held firmly at a right angle with 
the line of the leg and thigh or somewhat above it, while in congen- 
ital dislocation of the hip the pelvis drops. 

PROGNOSIS. 

In connection with general rickets, when coxa vara exists with other 
marked rhachitic deformities, the prognosis does not differ from that of 
knock-knee or bow-legs. In other cases there seems no reason to look 
for spontaneous cure. Remissions in the symptoms follow the rest ne- 
cessitated by the joint irritability and may be of considerable duration. 

TREATMENT 

in coxa vara is either expectant or operative. 

Conservative Treatment. — In the stage in which the bone may 
be regarded as congested and not sufficiently strong to support super- 
imposed weight, crutches or an apparatus which will remove weight 




Fig. 276.— Double Coxa Vara Showing Eversion of Feet and Outward Rotation of Legs. 

(J. E. Goldthwaite.) 

from the head and neck of the femur can be employed. A convales- 
cent hip splint (Chapter XXL, 11) or a Thomas knee splint (Chapter 
XXL, 14) can be used in unilateral cases. In bilateral cases hip-trac- 



COXA VARA AND COXA VALGA. 317 

tion splints with an abducted position of the limbs are indicated if the 
symptoms of joint irritation demand such thorough treatment. Mas- 
sage is of benefit in stimulating the circulation. When the deformity 




FIG. 277.— Case of Double Coxa Vara. This case was reported by Dr. George K. Monks 
in the Boston Medical and Surgical Journal, November 18, 1886. The photograph here 
shown is a recent one, having been taken for Dr. Monks three or four years ago. 

is slight, such measures may be relied upon not only to check an in- 
crease of the deformity and to allay the condition of hip sensitiveness 
which may follow overstrain, but also to favor correction by a more 
normal growth. 

Operative Treatment. — If the deformity is sufficiently severe to 
occasion disability, operative measures are indicated. These may be 
directed to restoring to the patient free motion in the direction of ab- 
duction or to the correction of deformity. 

Forced abduction may suffice in young children and can be accom- 
plished by abduction of the limb under anaesthesia with or without fas- 
ciotomy, and fixing of the limb for a month or more by a plaster spica 



3i« 



ORTHOPEDIC SURGERY. 



bandage in- an abducted position. After this, massage and stretching 
exercises should be prescribed. Protected use should then be resumed. 
Osteotomy can be either linear or cuneiform. In linear osteotomy 
the bone is divided by an osteotome, cutting across the femur below the 
trochanter minor, as described in 
hip disease. The limb is strongly 
abducted, the shaft being rotated in 
or out to correct the twist of the 





Fig. 278.— Fracture of Hip Four Years 
after the Accident. Shows eversion. 
(Whitman.) 



Fig. 279.— Fracture of Hip. Projec- 
tion and elevation of trochanter. 
(Whitman.) 



neck. Plaster fixation with the limb abducted should be maintained 
for from four to six weeks. In linear osteotomy a surgeon familiar 
with the procedure can divide the shaft as in osteotomy for knock-knee 
without a skin incision, using the osteotome to divide the skin. Linear 
osteotomy requires the exercise of some skill in its performance, with 
the expectation of an excellent result. After this, if the limb is brought 
into the straight position, the former depressed angle of the neck will 
be changed to a normal oblique inclination. The bone gap caused by 



COXA VARA AND COXA VALGA. 



319 



the rectification will, as is observed in Macewen's operation for knock- 
knee, fill by healing by blood clot and subsequent ossification. 

The advantage claimed for cuneiform osteotomy, or the removal of 
a wedge-shaped fragment from the femur just below the level of the 
lesser trochanter, is the certainty of a sufficient gap of bone to correct 
the deformity. The disadvantage is that the operation requires more 
dissection and destruction of tissue and causes shortening. 

In cuneiform osteotomy a three-inch incision is made on the outer 
side of the femur, from the top of the great trochanter down. The tis- 
sues are separated, and by means of an osteotome a wedge-shaped sec- 




FlG. 280.— Radiograph of a Severe Rhachitic Coxa Vara in a Patient Six Years Old. 

(Joachimsthal.) 



tionof the femur is removed. The apex of the section should be at the 
cortex of the femur opposite the lesser trochanter, which should not be 
divided. The upper section of the bone should be at right angles with 
the axis of the shaft and the lower section made at an angle, the base 



320 



ORTHOPEDIC SURGERY. 



of the wedge being three-quarters of an inch wide, the exact amount 
varying with the size of the bone. After the section has been made 
and the wedge of bone removed, the uncut inner surface of the femur 
is broken. The splintered fragment and the periosteum act as a hinge 
and no wire sutures are needed, the cut bone surfaces being placed in 
apposition, the top of the great trochanter being pressed against the 
ilium by abducting the limb. The limb should be fixed in a plaster 
spica bandage, holding the pelvis and femur securely. 

After-Treatment. — After the removal of the plaster bandage the 
motion of the limb should be encouraged without weight bearing by 
passive movements, massage, and going about on crutches. After this 
it is a matter of judgment in each case whether the patient may be al- 
lowed unrestricted activity or whether the neck of the femur may still 

possess too little resistance, in 
which case a protection splint 
should be worn. 

Traumatic Coxa Vara.— In 
cases seen long after the accident 
the treatment does not differ from 
that described for ordinary coxa 
vara. In recent cases, seen so 
soon after the accident that con- 
solidation has had no time to 
occur, the leg should be abducted 
and fixed in that position by a 
plaster-of-Paris spica. Traction 
may be required in exceptional 
cases. Unprotected use of such 
a leg should not be allowed for a 
year after the injury. 

Coxa Valga. 

Coxa valga is the name applied 
to the condition which is the re- 
verse of coxa vara. In this the 
angle between the neck and shaft 
of the femur is increased above 
140 . In connection with this deformity also twists of the neck of 
the femur may occur. It has been recorded as occurring in connec- 
tion with infantile paralysis, in connection with atrophy following old 
ankylosis of the knee-joint, in osteomyelitis of the pelvic bones, in 
severe rickets, and in osteomalacia. 1 It has been recorded following 




FIG. 281.— Radiograph of a Sagittal Sec- 
tion of a Specimen of Coxa Valga, 
Amputation of the Thigh having been 
Done in Childhood. (Turner.) 



burner: Zeitsch. f. orth. Chir. , xiii. 
Wien, 1899. 



Albert: "Coxa Vara und Valga," 



COXA VARA AND COXA VALGA. 321 

a severe fracture of the lower end of the femur and knee-joint. A 
congenital case ' has been reported of double coxa valga in which ap- 
parently neither rickets nor trauma was present as an antecedent 
cause. When symptoms have been reported they consist of an ab- 




FlG. 282.— Radiograph of a Case of Coxa Valga. (David.) 

ducted position of the leg with eversion, and adduction and inward ro- 
tation are limited. The gait is not unlike that in double coxa vara. 
A satisfactory treatment of the condition has not been formulated. 

1 David : Zeitsch. f. orth. Chir. , xiii. , ii. and iii., 360 (with literature). 
21 



CHAPTER XL 

LATERAL CURVATURE OF THE SPINE. 

Definition. — Frequency. — Sex. — Age. — Pathology. — Etiology. — Symptoms. — Di- 
agnosis. — Methods of record. — Prognosis. — Preventive measures. — Treat- 
ment. 

DEFINITION. 

By this term is understood a constant deviation of the spinal col- 
umn, or a portion of it, to either side of the median line of the body, 
with a resulting distortion of the trunk. The affection has also been 
called scoliosis and rotary lateral curvature. 

In French it is known as Scoliose, deviation laterale de la taille, and 
in German it is called Seitliche Riickgratsverkriimmung, and Kyphosco- 
liose. 

Lateral curvature is either congenital or acquired. The former va- 
riety, however, is rare ; when present, it is a result of imperfect or de- 
fective development. 1 

FREQUENCY. 

The affection is a common one, but its prevalence can only be esti- 
mated, as statistics gathered vary apparently according to the standard 
of the observer. 

Drachmann reports scoliosis in 1^3 per cent of 28,125 school chil- 
dren in Norway, while in Switzerland 2 24.6 per cent among 2,314 school 
children are reported to have had lateral curvature, in Moscow 29 per 
cent of scoliotics among 1,664 children were found by Hagemann, and 
in St. Petersburg 26 per cent among 2,333 by Kohlbach. 

Berend reports 900 scoliotic patients in 3,000 patients ; Langgaard 
700 in 1,000 cases; Schilling, 600 in 1,000 (Schreiber). Whitman re- 
ports that scoliosis was, next to bow-legs, the most common deformity 
at the out-patient department of the New York Hospital for Ruptured 
and Crippled Children. 

The distortion is seen more frequently in girls than in boys, but 
statistics as to the comparative frequency of the deformity in females 
as compared with males vary. It is placed by different observers at 
from seven to four females to one male. 

1 Vogt : " Moderne Orthopadik," p. 75. — Schreiber: " Orthopadische Chi- 
rurgie," p. 118. 

- Annales Suisse d'Hygiene Scolaire, 1901. 

3 2 2 



LATERAL CURVATURE OF THE SPINE. 



323 



IIS 



105 



t\ 



^7 



19 



94 



It is possible that if parents were as solicitous as to slight variations 
in the figures of their boys as of their girls, the statistics would show a 
greater proportion among boys than has been reported. In the lateral 
curvatures of young children (under five), the males are said to equal 
or to outnumber the females. When school children are observed, the 
proportion of males is very much greater than when the statistics are 
taken from patients coming for treatment. Some 
of the most severe forms are to be seen among 
males. 

Age. — Although it is probable that the dis- 
tortion exists to a slight extent at an earlier age, 
the majority of cases brought to the surgeon for 
treatment are from ten to sixteen years of age. 
Whitman reports 39 per cent under fourteen 
years of age, 48 per cent between fourteen and 
twenty-one ; Eulenberg, over 50 per cent between 
seven and ten years of age, and 10 per cent be- 
tween ten and fourteen. 

Lateral curvature, an abnormality in the 
shape of the trunk by which its symmetry is 
lost, is characterized by a curve and twist of the 
spinal column, causing an undue prominence of 
one side and other irregularities of contour. 

The deformity is more readily understood if 
the pathological changes are examined. 



MYLYMHL1IT 
u r- i&j-imioii-sjo-ysH-ion 



PATHOLOGY. 



Fig. 283. — Diagram show- 
ing the Progressive In- 
crease of Scoliosis dur- 
ing School Life. The 
lowest grade in school 
is placed on the left. 
The lower figure shows 
the number of children 
investigated in each 
grade and the figure at 
the top the number of 
scolioses found in each 
grade. (Scholder.) 



The pathological changes in true lateral curv- 
ature are not those resulting from destructive 
disease of the vertebrae, but are the alterations of 
bone induced by abnormal pressure and strain. 

The spinal column, as a whole, is bent and 
twisted, and the individual vertebrae are in places 
altered in shape as well as misplaced from their 
normal relation to the vertical plane of the trunk. 

The ribs and pelvis may be altered in shape. The muscles and liga- 
ments are altered in their tonicity and length, and internal organs may 
be displaced. 

Characteristic of the deformity is the combination of a side curve of 
the spinal column with a twist, the spinous processes as a rule pointing 
away from and the vertebral bodies being turned toward the convexity 
of the curve. This rotation is the result of the structure of the 
spinal column, which cannot bend to the side without twisting. 



324 



ORTHOPEDIC SURGERY. 



The changes seen necessarily vary according to the stage of the 
affection and the degree to which the deformity has developed. 

In the earliest stage of scoliosis slight if any anatomical change will 






i t5? 


**dfe a 


i 

m 




1 ; • 


|: ■ ■>•■ 
! . - ; % 

HP 

I '■■' 





FlG. 284.— Longitudinal Section of the Ver- 
tebral Column of a New-born Child, Show- 
ing the Absence of Physiological Curves. 
(Schulthess.) 



Fig. 285.— Side View of the Vertebral 
Column of an Adult Man. (Schult- 
hess.) 



be found in the bones, ligaments, or muscles ; but in the stage of fixed 
curves and in the latest phases of the affection, marked distortion of 



LATERAL CURVATURE OE THE SPINE. 



32$ 



the whole spinal column, as well as the individual vertebrae, is to be 
observed. 

Wherever a side curve with rotation of the spine has taken place, 
the bodies are crowded together on the concave and separated on the 
convex side of the curve. Growing bone adapts itself to altered press- 
ure, and in time the vertebral bodies will be found thicker on one side 

than the other, and changes in 
shape of the articulating and 
transverse processes will also 
take place. The transverse 





Fig. 286.— Torsion in Lateral Curvature. 

ber.) 



(Schrei- 



FiG. 287.— Distorted Pelvis in Lat- 
eral Curvature. 



processes are out of the normal plane ; the ribs follow the transverse 
processes, and show a characteristic projection on one side and flatten- 
ing on the other. 

If the column is curved laterally in two or three directions, rotation 
necessarily takes place in different parts of it in opposite directions. 
The projection of the ribs is naturally more noticeable than the projec- 
tion of the transverse processes without ribs, so that in the lumbar 
region the rotation seems slight when compared with that of the dor- 
sal region. 

The intervertebral cartilages necessarily twist with the vertebrae 
and are compressed on one side more than on the other in cases of 
marked curves ; in severe cases they will be found on measurement 
thicker on the side of convexity than of concavity, so that instead of 
being flat they are wedge-shaped from side to side. In some cases 
the rotation is more marked than the curve, the line of the spines being 
nearly straight, while the bodies are found badly out of line, the axis 
of rotation being near the spines. 

Wolff's Law. — The adaptation of bone to pressure has been formu- 
lated in what is known as Wolff's law, which is as follows: "Every 
change in the formation and function of the bones, or of their function 



326 



ORTHOPEDIC SURGERY. 



alone, is followed by certain different changes in their internal archi- 
tecture and equally definite secondary alterations of their external con- 
formation in accordance with mathematical laws." 

The relation of bone structure to strain, however, was understood 
and described by Sir Charles Bell in his 
treatise on "Animal Mechanics," and 
was also described by Jeffries Wyman, of 
Cambridge. 1 





Fig. 288.— Method Used for Producing Deformity of 
Head by Flat-Head Indians. (From Sketch from 
Lewis and Clark.) 



FIG. 289. — The Flat- 
Head Indian. An 
old man. 



There is necessarily a torsion of the spinal column whenever it is 
bent toward the side, and when a curved condition of the spine becomes 
habitual or constant the changed pressure in the spinal column pro- 
duces in time alterations in the shape of the vertebral bodies and in the 
articulating surfaces. 

It has been shown that not only do the bodies of the vertebrae give 
evidence of torsion around the axis of the spinal column, but there is, 
in advanced cases, evidence of torsion of the bodies themselves in 
oblique and spiral longitudinal striations on the bodies in the place of 




Fig. 290.— Transverse Section of a Scoliotic Thorax. (Albert.) 

the usual vertical marking, and in a twist of the spinous process and 
lamina in its relation to the vertebral body. 2 The bodies lose their nor- 



1902. 



Animal Mechanics," by Sir Charles Bell and Jeffries Wyman, Cambridge, 
2 Lorenz : " Scoliosis," Wien. 



LATERAL CURVATURE OF THE SPINE. 3 2 7 

mai symmetrical shape ; the spinal canal becomes irregularly oval in 
shape, and the transverse and articular processes are altered according 
to the position of the vertebrae; those on the crowded side being 
broader and lower than on the convex side. The changed vertebrae 
vary according to their relative position in the curve and to the direc- 
tion in which they receive the superincumbent pressure, those at the 
site of the greatest curve changing the most. 

On section the structure of the bones will be found normal, except 
that abnormalities in bone density and in the trabecular will be ob- 
served, and irregularities in shape and growth. 

The ribs are not only displaced, but altered in shape. They are 




Fig. 291. — Horizontal Section of a Normal Dorsal Vertebra. (Dolega.) 

also altered in the line of their obliquity, being lowered on the side of 
the concavity of the curve. 

The contour of the thorax is changed from the altered shape of the 
ribs ; the clavicles remain, as a rule, unchanged, but the tip of the ster- 
num may be deflected from the median line. The ribs project back- 
ward at the angle on the side of the convexity of the curve and forward 
on the side of the concavity. 

A cross section of the thorax shows an alteration of the diagonal 
axes of the chest, and in the ordinary dorsal right convex curve the 
diagonal axis from the left front side to the right back side of the thorax 
is longer than on the other side. The different halves of the thorax, 



328 ORTHOPEDIC SURGERY. 

on cross section, should be symmetrical normally, but in lateral cur- 
vature the portion on the convex side is smaller than that on the con- 
cave side, owing to the flattening of the ribs. The vertebral bodies 
are also crowded into this half of the thorax, so that there is less room 




FIG. 292.— Section of the Ninth Dorsal Vertebra in a Case of Right Dorsal Scoliosis. (Dolega.) 

for expansion of the lung on that side than on the other side. In the 
severest cases of distortion, the lower ribs on one side may rest upon 
the crest of the ilium or sink into the pelvic cavity. 

The muscles of the spinal column in an early case of lateral curva- 
ture are unaffected, except in cases of a purely paralytic nature. In 
dissections of advanced cases the muscles are found to have degen- 
erated. The muscles in the concavity of the curve are found neither 
prominent nor rigid. The prominence and rigidity of the spinal mus- 
cles in the lumbar region frequently seen on the convex side of the lum- 
bar curve often convey to the touch a doubtful sense of fluctuation, and 
have sometimes led to the suspicion of an abscess. 

In advanced cases of lateral curvature, the ligaments on the concave 
side of the spinal column are shortened and those on the convex side 
are elongated. This is the result of adaptive shortening, and is not 
found in the early stages of the affection. 

Distortion of the Pelvis in Cases of Lateral Curvature of the Spine. 
— The pelvis is not necessarily distorted in lateral curvature of the 
spine, but the bones of the pelvis may, if not sufficiently unyielding in 
their structure, become altered by abnormal pressure or strain. The 
pelvis may assume the appearance of obliquity from a prominence of 
one hip due to the uncovering of the crest of the ilium by the over-pro- 



LATERAL CURVATURE OF THE SPINE. 



329 



jecting ribs, but true obliquity is exceptional. When there is irregu- 
larity in the length of the legs, obliquity of the pelvis necessarily exists. 
The spinal cord is not affected by lateral curvature. The spinal nerves, 
in consequence of the large size of the foramina, are not liable to suffer 
compression, but symptoms of nerve-root pressure are at times observed 
in advanced cases. 

Influence of Lateral Curvature in Causing Displacement of Abdomi- 
nal Viscera. — The abdominal viscera are less likely to be displaced, 
even in severe cases, than the thoracic organs, though the liver may be 
out of place and altered in form, according to the direction and extent 
of the spinal distortion. The spleen may suffer some compression, 
and the aorta is necessarily displaced. The lung on the convexity of 
the curve is much more compressed and flattened, and the thoracic 
cavity on the concavity of the curve is always found to be much larger 




Fig. 293.— Experiment on Cadaver Showing the Causation of a Right Curve with Rotation 
from Oblique Superincumbent Weight. 



than would be expected. The lung on the concavity of the curve may 
be altered in form, but is not diminished in bulk as on the side of con- 
vexity. The heart is generally found displaced toward the concavity of 
the curve in severe cases. 



330 ORTHOPEDIC SURGERY. 

ETIOLOGY. 

When bone was regarded as a structure which was unchanged in 
shape except by accident or destructive disease, the phenomena of lat- 
eral curvature were not easily understood. No evidence of disease or 
traumatism is found, and, although the bones are abnormal in shape, 
they are not defective. It is now known that bone, like other portions 
of the human frame, muscle, and skin, is a structure which adapts itself 
to conditions, being changed in shape and strength under pressure and 
strain. Bone can be deformed by abnormal pressure without injury to 
the health, as is shown by the flat-headed Indians, whose skulls were 
shown by Clark to have been distorted by pressure mechanically applied 
for a long period in infancy. The foot of a Chinese lady is another 
illustration. The shape of the bone, as is well known, alters in differ- 
ent occupations. These alterations in bone, studied as they have been 
by Bell, Wyman, and Wolff, may be regarded as the result of altered 
conditions. 

The phenomena of lateral curvature, curve and rotation, have been 
produced experimentally on the cadaver of infants (Bradford and Lov- 
ett, ist and 2d eds., Chapter " Lateral Curvature"), and in animals by 
Wullstein, 1 who produced scoliosis by securing for six months the spine 
of a growing dog by a stiff bandage in a bent position. Growing chil- 
dren, obliged to retain an abnormal position through paralysis, often 
acquire scoliosis, and the Siamese twins, prevented from normal atti- 
tudes, developed similar deformities. It is not necessary to seek for 
remote causes in studying the etiology of scoliosis. 

To explain the development of scoliosis it is only necessary to as- 
sume the existence of a constantly applied force exerted upon the spinal 
column in abnormal directions. As the resistance offered by the bone 
differs in different portions of the spine, a certain type of deformity 
results from abnormally applied superimposed weight, and, as individ- 
uals differ, similar conditions do not produce the same deformity in 
different individuals. Whatever favors abnormal distribution of the 
superimposed weight favors the development of the deformity, as is also 
true of conditions which diminish the resistance of bone. Of the fac- 
tors favoring abnormal distribution of superimposed weight, the follow- 
ing may be mentioned : 

1. Faulty attitudes in standing or sitting. 

2. Inequality of the length of the limbs or other causes tilting or 
twisting the pelvis. 

3. Occupations which produce faulty attitudes. 

4. Paralysis or weakness of the muscles of the back. 

5. Congenital defects, absence or defects of the ribs or vertebrae. 

1 Wullstein: "Die Skoliose," Stuttgart, 1902. 



LATERAL CURVATURE OF THE SPLNE. 



331 



6. Torticollis or inequality of vision in the eyes. 

7. Contraction of the chest following empyema. 

8. Sacro-iliac disease. 

9. Asymmetry of the pelvis. 

Lateral curvature is also favored by causes which will diminish the 
resistance of bone to abnormally applied weight. Apart from disease 
of the structure of bone, these are: (1) rickets and osteomalacia; (2) 
abnormal lack of bone resistance of the spinal column, from rapid, ex- 
cessive, or ill-nurtured growth. 



SYMPTOMS. 

Early History. — The deformity of scoliosis is developed during the 
growing years, becoming arrested, as a rule, at the end of the period of 
growth. 

The affection is ordinarily discovered by the patient's mother at 
the age just previous to puberty, although it is developed earlier than 
this in a majority of cases without 
being recognized. The symptoms 
are so slight in the earliest stages and 
the deformity is so easily overlooked 
that the surgeon is rarely consulted. 
The patient suffers no inconven- 
ience at this stage, and as the child 
is at an age (five to ten) when the 
figure is not carefully scrutinized, 
little attention is paid to the slight 
elevation of the shoulder or projec- 
tion of the hip. Upon superficial ex- 
amination but little else is to be seen, 
and these symptoms disappear on re- 
cumbency or suspension. A careful 
examination often discloses a pecul- 
iarity in standing or sitting. 

In a majority of cases when the 
surgeon is consulted, well- marked de- 
velopment of the distortion has al- 
ready taken place, with more or less 
structural change. 




Fig. 294. — Front View of Lateral Curva- 
ture, Showing Prominence of Left 
Mamma in Right Dorsal Convex Curva- 



ture. 



The muscular system may or may 
not be well developed, but in a majority of cases the muscles are not 
large or strong. In the early periods of the development of the affec- 
tion there is rarely any symptom complained of except the annoyance 
of the curvature, due to a distortion of the figure. In a few instances 



332 



ORTHOPEDIC SURGERY. 



of growing girls with marked impairment of strength some thoracic 
pain may be felt, and fatigue on exertion in walking or standing. The 
period during which the curvature of the spine may develop is in- 
definite, as well as are the rate and extent of the development. It is 

impossible, in the present 
stage of our knowledge, to 
predict the amount of in- 
crease or the permanency 
of arrest. The liability to 
increase is greatest during 
the growing years. But 
cases of severe curvatures 
will be seen in which de- 
velopment has slowly con- 
tinued during the years of 
younger adult life. 

While it is certainly 
true that the time when 
a curve may be regarded 
as arrested is not easily 
recognized, an examina- 
tion of a large number of 
untreated cases justifies 
an opinion that spontane- 
ous arrest takes place in a 
very large number of the 
slighter cases, without fur- 
ther development of the 
deformity. Even in many 
of the severer types of the 
deformity patients will be observed who go through adult life without 
any increase of, or inconvenience from, the deformity. 

The symptoms of lateral curvature axe pain, impairment of general 
condition, and deformity. 

Pain. — Painful symptoms are not common in the affection, except 
in the severest cases. 

The symptoms of pain are of three classes : 

i st. Those due directly to the altered muscular or ligamentous 
strain. 

2d. Those due to the abnormal pressure from distorted ribs upon 
the nerves or ilium, or by vertebrae upon nerves, or to alteration of the 
size and shape of the thorax, and displacement of viscera. 

3d. Neurasthenic symptoms from a lack of vitality, superinduced 
by the limitations as to exercise and activity, consequent on the deform- 




FlG. 295. — Right Lateral Curvature. (Weigel.) 



LATERAL CURVATURE OE THE SPIKE. 



333 



ity, and to the impairment of circulation and respiration by the deform- 
ity of the chest. 

Impairment of General Condition. — Interruption in the functions of 
the liver, stomach, and intestines is occasionally seen in severe cases. 
Shortness of breath also occurs, as well as pain in the stomach, loss of 
appetite, and indigestion. In the severest cases a lack of deposit of fat 
in the subcutaneous tissue will be noticed, and the patients are thin, 
even though they ma}' be in relatively good health. 

Deformity. — The chief symptom of lateral curvature is the distor- 
tion. This, as has been explained, is not limited to a simple lateral 




Fig. 296.— Severe Lateral Curvature (Un- 
treated). 



FIG. 297.— Right Dorsal. Slight Left Lumbar 
Curve. 



curvature of the spine, but to this is added a twisting of the trunk; or, 
in other words, there is both a curvature and a rotation on a vertical 
axis. 

The curves of the spinal column vary in degree, situation, and ex- 
tent. There are, however, common types, which it is convenient to 
bear in mind in considering the subject of treatment. 

Lateral curvature either involves the whole spine in one curve, 
termed by some writers total scoliosis, or it is chiefly confined to a re- 
gion or regions of the spine, and the curvature is called cervical, dorsal, 



334 



ORTHOPEDIC SURGERY. 



or lumbar scoliosis. These are defined right or left, according to the 
direction of the convexity of the curves. 

What is termed double scoliosis is met when an upper curve is found 
in one direction and a lower in the opposite. 

If one lateral curve occurs in the middle region of the spinal col- 
umn, one or two other compensating curves are of necessity developed 
in opposite directions, to preserve the patient's balance, above or below 
the deformity, in order that the head be kept erect and in the median 
line. These compensating curves may or may not be of pathological 
significance. In some instances one of the compensating curves is of 
an equal prominence with the so-called primary curve ; in which case 

the spinal column will pre- 
sent the S-shaped curve 
which is characteristic. In 
other cases what is termed 
the compensating curve may 
become more marked. 

The curves are rarely 
limited exactly to definite 
portions of the spinal col- 
umn; the upper curve may 
be so long as to include all of 
the dorsal and upper lumbar 
vertebrae. Again, the lower 
curve may be so long as to 
invade nearly the whole of 
the dorsal region, the com- 
pensation taking place in the 
upper part of the cervical re- 
gion. 

In all varieties of curves 
except the total, compensat- 
ing curves, so called, are 
necessarily present. They 
may be so slight as not to 
attract attention. 

Furthermore, when the 
curves are in the flexible 
stage it is difficult to de- 
termine which is the more important one ; but after osseous changes 
have taken place, the most important curves become fixed, and these 
are the curves which demand most attention. This is partly due to 
the attitude in which the column is placed, and partly, probably, to 
a lack of resistance of tissues of certain parts of the spinal column. 




Fig. 298. — Severe Right Dorsal, Left Lumbar Curve 
Showing Marked Lumbar Rotation on the Left. 



LATERAL CURVATURE OF THE SPLNE. 



335 



Cervical Curvature. — The cervical or cervico-dorsal curves are the 
least common form of lateral curvature, except when associated with 
torticollis. 

This curvature may, however, occur primarily ; when it does, it is 
most commonly accompanied by a long compensatory lower curve. 
There is invariably elevation of one shoulder and an inclination of the 
axis of the head to the side of the concavity of the cervical curve. 

Dorsal Curvature. — The most 
common dorsal curve is with the 
convexity to the right. In these 
cases the right shoulder will be 
raised, the right shoulder blade 
will project backward more prom- 
inently than the left, and will be 
at a higher horizontal level and 
farther from the median line of 
the trunk. The back, just below 
the scapula, will be more rounded 
backward on the right side and 
more flattened on the left, and 
the left shoulder will be held 
down. In front, in well-marked 
cases, the breast and front of the 
chest may be more prominent on 
the left than on the right side. 

In addition to the curve there 
may be a tendency to displace- 
ment of the whole trunk to the 
right side. When this is the case, 
the right arm, when hanging, will 
be free from the side, while the 
left arm, when hanging down, 
necessarily strikes the hip. 

There is also, unavoidably, a change in the outline of the sides of 
the back. The sides, instead of being symmetrical, as seen from the 
back, will be different; one side of the outline will be unnaturally 
straight, and the other more than normally hollowed. 

The normal backward physiological curve in the dorsal region may 
be diminished so that the upper back is abnormally flat, or it may be 
increased so that the dorsal region is abnormally bowed. The latter 
condition is spoken of by German writers as kyphoskoliose. 

Lumbar Curvature. — Lumbar dorsal or lumbar curvature manifests 
itself by a prominence of one of the hips ; the one on the side of the 
concavity of the curve appears in the contour of the trunk higher than 




Fig. 299. — Right Dorsal, Left Lumbar Curve 
with Displacement of Body to the Right. 



336 



ORTHOPEDIC SURGERY. 



on the other side, as it is less covered by overlying tissue. It is often 
termed a "high hip," but incorrectly; measurement shows no differ- 
ence. In well-marked lumbar curvature there is also a fulness in the 
back on the one side, above the crest of the ilium, and a corresponding 
flattening on the other. In front the umbilicus is at the side of the 
median line. A marked difference in the outlines of the two sides of 
the back, already mentioned, is seen in this form of curvature. 

A combination of lumbar and dorsal curves in opposite directions, 

or compound curves as they 
have been termed, will present 
the features of both varieties, 
but the distortion of the most 
pronounced curve predomi- 
nates. 

Limping. — In severe cases 
of curves involving the lum- 
bar region the distortion of 
the vertebral column is so 
great that the pelvis is second- 
arily tilted, and by this one leg 
is rendered shorter than the 
other for practical purposes 
and a more or less marked 
limp may be caused. 

Structural and Postural 
Curves. — Curves will be found 
to vary not only in their local- 
ization and their amount of 
rotation, but also in their ri- 
gidity. This variation is due 
to the variation in the amount 
of structural change. For 
clinical purposes it is conveni- 
ent to apply the term structural 
curves to those with evident 
changes in the tissues, and pos- 
tural to those curves without definite structural changes. The latter 
are flexible and easily corrected by the patient's effort, by lying down 
or by suspension. In the latter, rotation is not a prominent symptom. 
These curves have also been designated as fixed or habitual. The 
terms primary and secondary curves are also used to define the relative 
clinical importance or severity of the two curves present. This appli- 
cation of the term is preferable to the use of these terms to designate 
the one first formed, as it is impossible to determine this in many cases. 




FIG. 300.— Left Total Curve Showing Elevated 
Left Shoulder. 



LATERAL CURVATURE OF THE SPLNE. 



337 



Rotation. — As is explained under the head of pathology, it is impos- 
sible for any curvature to take place in the spinal column without being 
accompanied by rotation. 

The prominence of rotation in lateral curvature is a measure of the 
severity of the case. 

The amount of rotation may be much greater in some cases than 
would be expected by the slight amount of apparent lateral deviation of 





Fig. 301. — Right Dorsal Curvature Follow, 
ing Empyema of the Left Side. 



FlG. 302.— Right Dorsal Curve, Showing Ele- 
vation of Right Shoulder, Prominent Left 
Hip, and Rotation of Right Chest Back- 
ward. 



the spinous processes, as if the vertebrae yielded more by twisting under 
superincumbent weight than by curving to the side. 

Rotation, as has been shown, is always toward the convex side of the 
lateral curve ; but in childhood the so-called total scoliosis often shows 
a general backward prominence of one side. The backward projecting 
shoulder will often be found on the concave rather than the convex 
side. This occurs only in a flexible spinal curve, where the compensa- 
tory curve is not easily recognized or entirely established. It is per- 
haps the initial stage of the ordinary type of scoliosis, the long curve 
being afterward divided into two sections. 

Relative Frequency of Curves. — The lateral curvature most com- 
22 



338 



ORTHOPEDIC SURGERY. 



monly seen by the surgeon is the right convex dorsal curve. To this 
is frequently added a lower curve with the convexity to the left. If the 
trunk is displaced to the right, as is often the case in long dorsal curves, 
the left hip is uncovered and appears more prominent than the right, 
the reverse being the case when the trunk is displaced to the left. 
When school children are examined irrespective of symptoms complained 
of, many postural curves not brought to the surgeon for examination 




Fig. 303. — Lateral Curvature Due to Empy- 
ema of Right Chest. Five months after 
operation. 



FIG. 



304. — Congenital Lateral Curvature As- 
sociated with Absence of Ribs. 



are seen. Of these, total curves will be found the most common, and 
of these, the one with the convexity to the left is the most frequent. 1 



VARIETIES OF LATERAL CURVATURE. 

Rhachitic Lateral Curvature. — This form occurs in rhachitic chil- 
dren, but it is not so common a curve as the simple posterior curve 
which appears as a backward prominence in the lumbar region in so 
many cases of rickets. In some varieties of lateral curvature there 
may also be an exaggerated antero-posterior curve clue to yielding of 

1 Liming and Schulthess : " Orth. Chir.," Munich, 1901, p. 246.— Zeitsch. f. 
orthopadische Chir., 1902, Bd. x. 



LATERAL CURVATURE OF THE SPINE. 



339 



the bones under the unusual distribution of superincumbent weight. It 
is probable that if cases with rickets were more carefully examined, 
scoliosis would be more frequently observed. Truslow : found it in 15 
per cent of 201 cases of lateral curvature, and Mayer 2 found scoliosis 
in 217 out of 220 rhachitic children. 

Difference in Length of Legs. — A slight difference in the length 
of the lower limbs is the rule. But development of lateral curvature 
directly from this cause is not invariable, as is evident from the fact 
that in cases of scoliosis a 
notable difference in the 
length of the lower limbs is 
detected, in about the same 
proportion of cases as in nor- 
mal children. In children 
with marked inequality in 
the length of the legs and 
with diminished resistance 
in the vertebral column, sco- 
liosis will follow. 

Paralytic Lateral Curva- 
ture. — In a certain number 
of cases of paralysis of the 
muscles of the back lateral 
curvature of the spine is 
found. 

When the muscles of the 
back are weak, the patient 
instinctively assumes an at- 
titude in which the spine is 
balanced with the least action 
on the part of the weakened 
muscles. The curvature may 
be toward the side of the 
paralyzed muscles or away 
from them. 3 The bones of 
the spine may be distorted 
(if lacking in a power of resistance) by a constant vicious attitude, 
and a fixed lateral curvature result. 

This form of lateral curvature is most commonly developed after 
infantile paralysis, as this is the most common form of paralysis occur- 
ring in the growing years ; but the effect of other palsies, if influential 

1 Whitman : " Orthopedic Surgery." 
2 Bulletin Medical, June 15th, 1901. 
3 Arnd: Arch. f. Orthopadie. vol. i., No. 1. 




Fig. 305.— Left Lumbar Dorsal Curve. 



340 



ORTHOPEDIC SURGERY. 



in weakening certain muscles of the back, would be the same, and the 
distortion may be seen after spastic paralysis, progressive muscular hy- 
pertrophy, syringomyelia, and other affections weakening the muscles 
of the spinal column. 

Torticollis. — Affections causing unequal muscular contraction of the 
muscles of the back will throw the spine out of balance. In this cate- 
gory torticollis is to be mentioned, as lateral curvature always follows 
this affection unless it is corrected. Inequality of vision and hearing 




FIG. 306.— Severe Curvature due to Rickets. 



and congenital conditions causing the head to be held to one side (T. 
D wight) are possible causes of scoliosis. 

Lateral Curvature from Contracture of the Chest.— Lateral curva- 
ture may follow empyema, and some deviation of the spinal column is 
likely to follow severe forms of empyema. In the purest forms of this 
type the spine is pulled to one side, the ribs being flattened, i.e., fixed 
obliquely at a lower angle than normal, from the cicatricial contrac- 
tion of the lung which prevents expansion of the lung on that side 
and leads to an increased expansion on the other. In certain cases 
the altered position so induced has its effect upon the growth of the 
spine. 



LATERAL CURVATURE OE THE SPINE. 



341 



It has been said that a curvature followed in some instances pneu- 
monia, phthisis, and organic heart disease. 

Lateral curvature may follow sarcoma of the ribs and lung. 1 

Lateral Curvature from Occupation. — Any occupation which neces- 
sitates faulty attitudes for long periods daily, favors the development of 
spinal curve, but lateral curvatures of severe type due to ordinary oc- 
cupation are not, as a rule, common, for the reason that laborious occu- 
pations are not, in general, entered upon until an age when the spinal 
column has a sufficient amount of resistance to withstand the superim- 
posed weight without developing great structural change. 

Slight lateral curves may be seen, analogous to the kyphosis of 
those employed in occupations requiring stooping. In clerks one 




Fig 



-Severe Case of Spastic Paralysis in a Patient who had never Walked and who from 
Childhood had Sat to One tSide. The patient is now an adult. 



shoulder is often higher than the other from the attitude of writing, 
and it is said to be true also in blacksmiths. Severe forms of this class 
are sometimes seen in adolescents whose occupation habitually twists 
the spine, as in carrying baskets or trays. 2 

Scoliosis in nursing women, from carrying infants too frequently 
upon one side, is also recorded, and the same attitude in one-armed per- 
sons. 

Scoliosis seen in school children is in reality generally an occupa- 
tion deformity, resulting as it does from the constant assumption of 
faulty attitudes, which produce abnormal pressure and strain upon 
growing spinal columns lacking in structural resistance. 

Congenital defects in the spinal column with misshapen vertebrae 

1 Boston Med. and Surgical Journal, January 10th, 1889. 
-Zuppinger: Zeitsch. f. orthopadische Chir. , xi., p. 280 



342 



ORTHOPEDIC SURGERY. 



is a cause of congenital deformity, but it is impossible in the absence 
of reliable statistics to determine how commonly this occurs. 

Alteration in the shape of the vertebra from disease (Pott's disease, 
osteomyelitis of the spine, and spondylitis deformans) may cause lateral 
curvature. It may also occur in Pott's disease and sacro-iliac disease 
as the result of muscular spasm. 

Ischias scoliotica, referred to also as scoliosis neuromuscularis, or 
neuropathica or ischiatica, is a term which 
has been applied to lateral curvature in the 
lower part of the spinal column occurring 
in connection with sciatica. It is severest 
in cases in which the lumbar nerves are 
involved. The curvature may be to the side 
of the affected nerve, or the reverse, or it 
may alternate. The condition is most easily 
relieved by fixative appliances. 

DIAGNOSIS. 

A diagnosis of lateral curvature, in a se- 
vere case, is so simple that an inspection of 
the patient is all that is required. 

In the less-marked cases, however, the 
recognition of the true nature of the de- 
formity is not so easy, and a careful examina- 
tion is necessary, not only for the exclusion 
of other affections of the spine, but also 
for an estimate of the progress of the lateral 
curvature and the amount of rotation and 
bony change in the spinal column. 

The method of examination of a case of 
lateral curvature is as follows : 

The patient's back should be bared in 
ordinary cases to the level of the trochanters, 
and the arms should be allowed to hang 
free. The most natural attitude in standing 
should be noted and also the position of 
the patient in an attempt to stand in as straight a position as is pos- 
sible; the tips of the spinous processes are to be marked with a skin 
pencil, and also the ends of the scapulae. To determine the central 
line a string, to which a slight weight is attached, is hung from the sev- 
enth cervical vertebra (to which it can be fixed by a piece of adhesive 
plaster), the string being long enough to hang below the cleft of the 
buttock ; or the string should be used as a plumbline to show a perpen- 
dicular, erected from the middle of the pelvis. In this case it hangs in 




FIG. 308.— Lateral Curvature due 
to Infantile Paralysis of Mus- 
cles of Trunk. 



LATERAL CURVATURE OE THE SPLNE. 343 

the cleft of the buttock, and the deviation of the spine from this verti- 
cal line can be noted. The distance of the tips of the scapulae (the 
arms being crossed in front of the chest) from this central line should 
be measured, and also the distances from this line to the points of 
greatest curvature of the line of the spinous process. These points be- 
ing noted, the slope of the shoulders, the outlines of the sides of the 
trunk, and the contour of the back, as well as any lack of symmetry or 
unilateral fulness, should be carefully recorded, both when the patient 
is standing and in the stooping position, with the back well arched. If 
a side deviation of the line of the spinous processes is observed, a lack 
of symmetry of outline, or a unilateral projection of the ribs or scapulae, 
in the erect position, it should be recorded and the patient should be 
suspended by means of a head sling and also made to lie in a recum- 
bent position upon the face. A marked alteration of the curvature, 
contour, or outlines following removal of the superincumbent weight is 
of particular importance. 

If the curve disappears under these conditions, it is to be classed as 
postural. If it does not disappear, it is to be considered structural. 

The patient should then bend forward with the knees straight and 
the arms hanging until the trunk is horizontal. In the normal spine 
the two sides of the back will be on a level when viewed in this posi- 
tion. Rotation of the ribs or lumbar vertebrae due to structural 
changes is shown by a greater upward prominence of the side of the 
back which has rotated backward. This may be measured, if desired, 
by a plumbline hanging from the angle between the arms of a pair of 
calipers. This plumbline records the variation from the horizontal in 
a protractor fastened at the angle of the calipers, or the apparatus 
{Nivelliertrapez) of Schulthess * may be used for the same purpose. 

The flexibility of the spine should be tested by causing the patient 
to stand first with one foot and then the other upon a series of blocks 
half an inch in thickness, and testing what height can be placed under 
the patient's foot without preventing her from standing upon both legs 
with the limbs straight, without flexion at the knee ; this tests the lat- 
eral flexibility in the lower part of the spinal column. In testing the 
flexibility higher up, the patient should be seated on a stool, and one 
hand of an assistant be placed upon her side, above the crest of the 
ilium, while the other hand should be placed upon the crest of the 
ilium of the opposite side. The patient should then be directed to 
bend sideways toward the side of the higher hand, and the amount of 
this motion, without tilting of the pelvis, is to be noted. 

The lateral flexibility can also be readily seen by directing the pa- 
tient to bend to the side with the hands behind the head and the feet 
apart, keeping the legs straight and avoiding twisting the pelvis. 
1 Liming and Schulthess : " Orth Chir.." Miinchen. 1901. p 153. 



344 ORTHOPEDIC SURGERY. 

It is not always necessary to examine the front of the patient's 
trunk in the case of older patients. When this is done, the projection 
of the ribs in front, and the difference in the prominence or flatness of 
the two breasts, the deviation of the tip of the sternum and of the um- 
bilicus from the median line are of importance, as indicating the amount 
of structural change which has taken place. The asymmetry of outline 
is always to be more clearly seen from the front than from the back of 
the patient. 

The strength of the muscles of the patient's back may be tested, if 
desired, by means of a dynamometer, or spring balance, and the height 
and weight should be recorded and compared with the normal standard 
for the age as given. 

A diagnosis of lateral curvature in the early stage is to be made by 











Fig. 309.— Measurement of the Rotation of the Ribs in the Horizontal Position by the Levelling 
Trapezium of Schulthess. (Schulthess.) 

observing in any case an habitual lack of symmetry in the outline of 
the sides of the trunk and the slope of the shoulders, in the unnatural 
projection of one shoulder blade or a portion of the trunk on one side 
or of one hip, and on a constant deviation of the line of the spinous 
processes from the vertical line. 

The accidental assumption of a faulty attitude does not justify a diag- 
nosis of lateral curvature ; but the habitual assumption of such a posi- 
tion, when the patient stands in the attitude of ease and greatest com- 
fort, indicates an abnormal condition. The existence of slight grades 
of lateral curvature is made more evident by allowing the patient to 
stand for a minute before beginning the examination, in order to obtain 
the relaxed position due to beginning muscular fatigue. 

The amount of structural change is indicated by the amount of stiff- 
ness and by the slight change in the curves and asymmetrical symptoms 



LATERAL CURVATURE OF THE SPLNE. 



345 



as the patient alters the position by standing, lying, bending, twisting, 
and hanging. In this way it is possible to determine the amount of 
progress the distortion has made and the stage of the affection. 

Lateral curvature is not infrequently confounded with Pott's disease 
through ignorance of the nature of either affection, both being classed 
as chronic spinal affections. In pro- 
nounced lateral curvature, the lateral 
twist and the rotation are essentially 
different from the curve of Pott's dis- 
ease, which is chiefly an anteropos- 
terior curve. In the former, rotation 
is an unmistakable symptom ; in the 
latter, it is absent or slight. In the 
slighter cases of lateral curvature the 
spine is flexible and the lateral curve 
diminishes or disappears on recum- 
bency ; and there is never a sharp angu- 
lar projection. In Pott's disease the 
spine is not flexible but stiff, the curve 
is angular, and it does not disappear 
on recumbency. Lateral curvature oft- 
en exists in Pott's disease, but is a lean- 
ing of the whole body to one side and 
is associated with the signs of destruc- 
tive disease. 



Methods 



of Recording 
Curvature. 



Lateral 



For clinical purposes a careful record 
of lateral curvature is necessary. 

In recording lateral curvature it is 
desirable to note the flexibility of the 
spine, the curve, and the amount of twist 
or rotation, as well as the attitude and 
contour. Photography, if carefully em- 
ployed, is of assistance. 1 For this pur- 
pose the spinous processes should be 
marked, and a line drawn from the sev- 
enth cervical spine to the cleft of the 
buttocks, which marks the median line of the body. The patient if: 
standing should be placed squarely before a camera and photographed 
with an arrangement of light to prevent strong shadows. The rotation 
can be photographed if the standing patient stoops and the camera is 
1 Spelissy : Trans. Am. Orth. Assn., vol. xv. 




Fig. 310.— Apparatus for Recording 
Lateral Curvature. (Feiss.) 



346 



ORTHOPEDIC SURGERY. 



focussed on the portion of the back showing the greatest rotation of 
the spine. 

A more ready but less reliable means of record can be furnished by 
the following measurements made and recorded from the spinous proc- 
esses to the line connecting the two ends of the spine : First, the dis- 
tances between the line from the seventh cervical spine to the cleft 
of the buttock and the points of maximum curve of the line of the 
spines in the upper and lower curve if both exist are recorded ; second, 
the distance from the spine of the seventh cervical vertebra to the 
point where the line connecting the ends of the spine crosses the line 
of curve. 

A simple apparatus devised by H. O. Feiss, of Cleveland, gives a 
fairly accurate record of the deformity by means of series of horizontal 



Li.anf.Su/i.s/iine 



Rt ani^u/t.spine 




% ^ fa. dorsal s/tiicc 



Fig. 311.— Tracings of a Case. The unbroken line representing the tracings at the level of the 
anterior superior spines and the broken line the tracing at the level of the tenth dorsal 
vertebra. (Feiss.) 



tracings of the trunk at different levels, superimposed on each other in 
a constant relation to the median plane of the body. The patient 
stands on a platform, from the back of which projects a square, vertical 
upright, upon which slides a horizontal arm carrying at its ends two 
horizontal arms projecting forward. The patient stands back to the 
upright, and one horizontal arm is behind him and one is on each side. 
The anterior superior spines are marked by a pencil. By means of 
holes in these arms, through which a skin pencil can be inserted, three 
marks on the patient's skin are now made at the level of the anterior 
superior spines, one on the patient's back and one on each side. The 
upright is then pushed up to the level of the greatest deformity, and by 
using the same holes in the uprights three more marks are made on 



LATERAL CURVATURE OE THE SPINE. 



347 



the skin in the same vertical planes as the others. Points are marked 
in the same way at other levels if desired. Horizontal contour tracings 
of the back and front of the patient at the levels of the marked points 
are made by means of a "draughtsman's adjustable rule." The poste- 
rior lower tracing is taken first and the points on the skin are marked on 
the tracer, and this tracing is reproduced on paper ; the anterior part of 



1* 28 20 




Fig. 312.— Apparatus for Recording Lateral Curvature. This machine records the antero- 
posterior curves, the line of the spine and outline of the body in the lateral plane and the 
horizontal contour of the back at any level. (Schulthess.) 



the tracing is then taken and laid out on the paper. The anterior and 
transverse lines of the apparatus are represented by lines drawn by a 
T-square. The second tracing is taken in the same way and drawn 
upon the paper, the marked points being made to lie over the same 

A series of tracings is thus graphi- 



points in the first tracing drawn 



34§ ORTHOPEDIC SURGERY. 

cally recorded, which bear the same relation to each other as the con- 
tours of the patient do at the recorded levels. 1 

Records taken in this way will serve for clinical purposes, but they 
lack scientific precision, as the possibilities of error on the part of the 
recorder are too great to be neglected. The methods answer for the 
use of a single observer, but not for a comparison of results in the prac- 
tice of different surgeons. 

The best and most accurate method of record is that to be obtained 
by the apparatus of Schulthess. The patient stands in a frame with 
the pelvis secured, and, by means of a pantagraph working from a 
bridge sliding up and down in the frame, an accurate record of the lat- 
eral deviation of the spinous processes, the antero-posterior curve of the 
spine, and the amount of rotation at different levels is obtained. The 
apparatus is expensive and complicated. 2 

PROGNOSIS. 

Two errors in prognosis are common. First, that the disease is of 
the most serious nature ; second, that it is a trivial affection and will 
be readily outgrown by the patient. The fact is, that in the larger 
number of these cases the affection is a self-limited one, occasioning 
slight deformity, which persists through life, causing no trouble and 
recognized only by the dressmaker or by some near relative. 

In other cases, however, the disease becomes decidedly worse as the 
deformity increases, and a pitiable distortion follows, causing a marked 
deformity and perhaps neuralgic pain. 

It is impossible to state positively in what instances an increase of 
the curve will take place and when they can be relied upon to remain 
stationary. It may, however, be said that when the physical condition 
during the growing period remains constantly below the proper stand- 
ard, and when the patient's growth is rapid, an increase of curve is to 
be apprehended. The decrease or diminution of lateral curvature from 
simple growth without treatment is not to be expected. 

Sometimes the disease may remain to a slight extent during girl- 
hood and early womanhood, developing an increase at a period past 
middle life. Such cases are dependent upon a loss of general health 
and upon trophic changes occurring at this period of life. 

In determining the prognosis the probable rate of growth is to be 
borne in mind. 

This can be ascertained by the patient's height, the hereditary ten- 
dency toward height as ascertained by the height of the parents and 
the parents' families. The general opinion is that comp^tion of growth 
exerts a powerful influence in arresting progress of the curvature. 

1 H. O. Feiss : Boston Med. and Surg. Journ , 1905. 

2 Liming and Schulthess: " Orthop. Chir ," Miinchen, 1901, p. 147 



LATERAL CURVATURE OE THE SPLNE. 



349 



In general it may be said that if a patient has gained full height and 
development in figure, any increase in growth is not often to be ex- 
pected, and that an increase in curve is not probable after the osseous 
system has become thoroughly formed and the strength of the spinal 
column established. 

The normal height and weight of male and female are here given 
for the sake of reference. 

Table of Height and Weight of the Human Body. 
Male. 



Age. 



At birth 
i year 

2 years 

3 " 

4 " 

5 " 

6 " 

7 " 

8 " 

9 " 
io 

12 " 

14 " 
16 " 
18 " 

20 

30 " 

40 " 



Height in Feet and Inches. 




Weight. 


1 ft. 7 in 


(0.496 m.) 


7 


lbs. ( 3.20 kgm.) 


2 " 3 " 


(0.696 " ) 


22 


" ( 10 00 " ) 


2 " 8 •' 


(0.797 " ) 


26 


(12.00 " ) 


2 " 9 " 


(0 860 •' ) 


29 


(13 21 ) 


3 " 


(0.932 " ) 


33 


(15 °7 ) 


3 " 3 " 


(0 990 " ) 


36 


" (16.70 " ) 


3 " 5 u 


(1 046 " ) 


39 


" (18.04 " ) 


3 " 8 " 


(1. 112 •' ) 


44 


" (20.16 " ) 


3 " 9 " 


(1-170 " ) 


49 


" (22.26 " ) 


A" 


(1.227" ) 


53 


(24.09 " ) 


4 " 2 " 


'1 282 " ) 


57 


" (26 12 " ) 


4 " 6 " 


d-359 " ) 


68 


" (31 00 " ) 


4 " 10 " 


(1 487 " ) 


89 


• (40 50 " ) 


5 " 3 " 


(1.610 " ) 


117 


" (53 39 " ) 


5 " 6 " 


(1.70° " ) 


135 


" (61.26 " ) 


S " 8 " 


(1.711 " ) 


143 


" (65.00 " ) 


5 " 9" 


(1.722 " ) 


150 


" (68.29 " ) 


5 "' 9 ' l 


(1.722" ) 


i5 2 


" (68.90 u ) 


5 - 8 " 


(I-7I3 " ) 


151 


" (68.63 " ) 



Female. 



Age. 



At birth 

1 year 

2 years 

3 " 

4 " 

5 " 

6 " 

7 " 

8 " 

9 " 
10 " 
12 " 
14 " 
16 " 
18 " 
20 " 
25 " 
30 " 
40 " 



Height in Feet and Inches. 



I ft. 


6 in 


(0.483 m.) 


2 " 


3 " 


(0.690 " ) 


2 " 


6 " 


(0 780 " ) 


2 " 


9" 


(0.850 " ) 


3 " 




.(0.910 " ) 


3 " 


2 " 


(0 974 " ) 


3" 


4 " 


(1 032 " ) 


3 u 


7 u 


(1.096 " ) 


3" 


9 " 


(I-I39 " ) 


3 " 


11 •' 


(1.200 "' ) 


4 " 


1 " 


(1.248 " ) 


4 " 


4" 


(i-3 2 7 " ) 


4 " 


9 u 


(i-447 " ) 


4 " 


11 " 


(i 500 " ) 


5 " 


1 " 


(1.562 " ) 


5 ' k 


2 " 


(i-57o" ) 


5 " 


2 " 


d-577 " ) 


5 " 


2 " 


d-579 " ) 


5 " 


1 " 


d-555 u ) 



Weight. 



6 lb 


s. ( 2.91 1 


:gm.) 


20 " 


( 9-30 




25 


(11 40 


) 


27 


(12 45 


) 


31 


(14.18 


) 


34 " 


(15 50 


" ) 


37 


(16.74 


" ) 


40 ' 


(18.45 


" ) 


43 " 


(19 82 


" ) 


5o " 


(22 44 


) 


53 " 


(24.24 


) 


67 ' 


(30 54 


" ) 


84 k 


(38 10 


" ) 


98 ' 


(44 44 


" ) 


117 k 


(53 IO 


" ) 


120 ' 


(54 46 


" ) 


121 


(55.08 


" ) 


121 


(55 14 




129 ' 


(58.45 


/ 



35o 



ORTHOPEDIC SURGERY. 



Prognosis under Treatment. 

Theoretically, lateral curvature is a deformity which can not only be 
prevented, but if treated in time can be cured. Practically, cases are 
often brought to the surgeon after structural changes have taken place 
and the tissues have become resistant. They are often in the condition 
of cases of humpback after a cure has been established with a persis- 
tent deformity, when a complete rec- 
tification of the curve is not advisable 
on account of the severity of the 
treatment. If cases of scoliosis have 
little structural change, improvement 
can always be obtained, and often this 
can be made a permanent cure. In 
cases with evident structural change 
in the growing years, diminution of 
the curve is to be expected to follow 
thorough treatment. In rigid cases 
an improvement of condition and car- 
riage can be hoped for. The pros- 
pects of treatment are, of course, 
better when it can be carried on dur- 
ing the period of growth. 




FIG. 313.— A Record Made by the Machine 
Shown in Fig. 312. At the left is the 
outline of the upright spine. Below are 
the contours of the back at three dif- 
ferent levels. (Schulthess. ) 



PREVENTIVE MEASURES. 



As faulty attitudes exert an in- 
fluence in causing lateral curvatures, 
the avoidance of these is of importance in preventing curves. 

Attitude at School. — The attitude assumed during school work de- 
serves careful consideration, as the injurious effect of improper attitude 
has been proved by statistics which show the prevalence of curvature 
among school children, and by the increase of the deformity in school 
years. 1 The prevalence of faulty attitudes in school has been shown 
by Scudder 2 and others. In an examination of the attitudes of 1,484 
school children seated in the schools of Boston and its neighborhood, 
sixty-seven per cent were found to be in incorrect position at the time 
of observation. 3 

An examination of the attitude assumed in writing by sixty -seven 
healthy adult males, while writing in a three-hour written examination, 

beholder: " Schuleskoliosis." Archiv f. orthop. Chir., i., 2.— Freeman: Ar- 
chives of Pediatrics, June, 1904 

-Report Boston School House Dept. , 1904. 
3 L. M. Towne : " Physical Education Review." 



LATERAL CURVATURE OF THE SPINE. 



35 



showed at the end of two hours that in all the paper was inclined 
slightly, so that the written line formed an angle with the cross axis of 
the thorax. This angle varied from ten degrees to a right angle. The 
inclination of the paper was always such that the right upper corner 
was in front of the left. In a large majority of the writers the left side 
of the hip was in front of the right, the left shoulder in front of the 
right, but the left ear was usually slightly lower than the right and 
somewhat behind it. In all cases, therefore, there was a slight rotation 
of the spinal column. The trunk in three-fourths of the writers was 
inclined to the left, in about one-quarter to the right, and in the re- 
mainder it was held erect. It may be fairly assumed that, if a twist of 
the spinal column is invariable in writing in strong men, faulty atti- 
tudes will be equally common in weakly children. 

School Furniture. 

In the prevention of scoliosis proper school furniture is essential. 

Seats. — Chairs used by children rarely support the back muscles 
adequately, which may be unduly stretched and thereby weakened. 
Children often assume faulty attitudes simply for the reason that proper 
support is not furnished the lower • -*> 

part of the back. They are apt to j *^ 

sit sideways, the trunk being sup- 
ported on one tuberosity of the is- 
chium. The seat of the chair in 
which the child is to sit for any 
length of time should not be deeper 
than the length of the thighs or 
higher than the length of the legs ; 
its back should not be above the 
shoulders and should be arched so 
as to fit in the hollow of the back. 

If this is not done, the large 
muscles of the back will be unduly 
strained, as they are inserted into 
the broad fascia which is attached 
to the sacrum and iliac bones, and 
faulty attitudes will be instinctively 
assumed by the patient. This is 
shown if tracings be taken of the 
back of a child in the various attitudes of sitting, leaning forward, back- 
ward, and sitting unsupported. 

The back of the chair should slope backward slightly, forming an 
angle of ioo° to uo° with the seat. The back of the chair should be 
arched with the convexity forward, the greatest convexity correspond- 



J 




FlG. 314. — Diagram o£ the Adjustable Schoul 
Chair Adopted by the Boston Schoolhouse 
Commission. (F. J. Cotton.) 



352 ORTHOPEDIC SURGERY. 

ing to the physiological curve in the hollow of the back. The back of 
the chair should be constructed so that it will serve as a support to the 
spine when the child leans backward, and especially to that portion of 
the back which is in most need of support and subject to the greatest 
strain, i.e., the lumbar region. The backs of most chairs simply touch 
the shoulders of children in the upper dorsal region. 

The following measurements are adapted from Staff el :* 

I. II. III. IV. 

6-9 9-12 12-15 Adult 

years. years. years. * 

Height from seat to floe 33 cm. y] cm. 41 cm. 47 cm. 

Height from seat to middle of lumbar pro- 
jection of chair. . 21 " 23 " 25 " 27 " 

From edge of seat to vertical line drawn from 

lumbar projection to seat. 26 " 30 " 34 " 38 " 

The writing-table should be at a height proportionate to the height 
of the person sitting. The distance from the top of the seat to the top 







_ 


\ 








A T^. 





FIG. 315.— School-room Fitted with Adjustable School Chair in Use in the Newer Boston 
Schools. (Report of Boston Schoolhouse Commission, 1904.) 

of the table should be one-eighth of the height of a girl, and one-seventh 
of that of a boy. The height can also be determined in the following 
ready way : The distance from the olecranon of the bent arm to the 
seat with two inches added should be the distance from the seat to the 
top of the desk. The edge of the table should be just over the edge of 
the chair. The inclination of the top of the desk should be a slope of 
two inches in a breadth of twelve. Adjustable school furniture is of 
1 Staff el: Centralblatt f. orthop. Chir., May 1st, 1885. 



LATERAL CURVATURE OF THE SPINE. 



353 



great importance in furnishing to school children suitable desks and 
seats. 

The chair adopted by the Boston School Commission after experi- 
mentation and measurement, and adopted for use in 1903 in all new 
and refitted school-rooms, is one meeting most of the requirements and 
one which has proved practically of use. 1 

A chair furnishing support to the back and permitting a change of 
position without loss of support has been devised by Professor Miller 
of the Massachusetts Institute of Technology and Dr. Stone, of Boston." 

Attitude in Writing. — That the development of scoliosis may be 
influenced by a twisted attitude in writing would appear from the dif- 




FlG. 316.— School-room Shown in Fig. 315, Showing Scholars Seated. (Report of Boston 
Schoolhouse Commission, 1904.) 

ferent percentage of spinal curvatures found in different schools in dif- 
ferent cities, where the oblique and vertical writing are taught : 3 

Oblique Writing. Vertical Writing. 

Per cent. Per cent. 

Nuremberg 24 15 

Zurich 32 12 

Munich 24 15 

Furth 65 31 

Wurzburg 28 8 

Although too much credence can easily be given to statistics with 

1 Reports of Boston School Commission, 1903 and 1904. 
-Trans. Amer. Orthopedic Assn., vol. xii. 

3 Schulthess: "School Scoliosis," Hamburg-, 1903. — Scholder : Arch. f. 
orthop. Chir. , i., 3. 
23 



354 ORTHOPEDIC SURGERY. 

such variation of percentages, it would appear to be probable that in 
oblique writing especial pains will be needed to prevent a twisted atti- 
tude in writing. 

The proper attitude during writing is with the transverse axis of 
the trunk parallel with the edge of the writing table. The forearms 
should rest at least two-thirds of their length upon the table. The 
trunk should be held erect, the legs should be straight before the trunk. 

School Hygiene and School Gymnastics Proper lighting of school- 
rooms and the correct placing of blackboards are essential in favoring 
proper attitudes. The avoidance of long sitting periods by introducing 
gymnastic exercises and changes of position is of importance. 1 It is 
evident that gymnastic exercises are of little benefit if not carefully 
and efficiently supervised. 

Correct Carriage. — Faulty attitudes are frequently assumed in walk- 
ing and in standing, especially by young children. The inclination to 
stand upon one leg is usually a habit, but in some cases it may be due 
to a muscular weakness of one limb or of a knee or ankle. The habit 
is to be corrected by drill or by muscular exercise, and by encourag- 
ing activity with the necessary constant change of position. Incorrect 
habits in sitting at home are to be remedied by insisting that the chil- 
dren with curvature shall not sit curled up or bent over in reading, but 
that they shall sit in suitable chairs and hold the book correctly. 

Attitude during Sleep. — The most common attitude in sleep is upon 
the side, but decubitus upon the back is more common than on either 
single side. The right side is more commonly lain on than the left, but 
the difference is slight; young children and men not infrequently lie 
upon the belly, but the attitude is not assumed by women or growing 
girls. 

The fact that a right-sided decubitus is to be avoided in a right dor- 
sal convex curve makes these facts of value. 

In ordinary cases the precautions at night which should be observed 
are that the patient should not be allowed to sleep with many pillows 
and that the bed should be a firm one. The child should not be al- 
lowed to assume a twisted position, but should lie upon the back or the 
side of the greatest concavity. In threatening cases measures are nec- 
essary to preserve a proper position. This can be clone by means of 
bed frames, described under Pott's disease. 

Proper Clothing. — Much has been said about the injurious effects of 
corsets, and there is no doubt that the muscles of the trunk are weak- 
ened by the wearing of them. 2 The injury from compression may be 
made less by elastic lacings and by the use of waists instead of corsets. 

1 Report National Committee on Education, Washington, 1894-95, p. 449- — 
Ibid., 1895-96, p. 1 174. 

2 Hutchinson : New York Medical Record, April 27th, 1889, p. 464. 



LATERAL CURVATURE OF THE SPLNE. 355 

That growing girls should be furnished with clothing which does not 
constrict the trunk needs no argument. The use of side garters, which 
fasten tightly drawn long stockings to waists dragging upon shoulder 
straps and shoulders, is to be avoided. This can be done by the use of 
round garters or attaching the garters to properly constructed shoulder 
straps independent of the waist and designed to draw the shoulders 
backward and not forward. Heavy petticoats should not be attached 
to waists with shoulder straps dragging upon the shoulders of growing- 
girls. This can be avoided by the use of union suits for underwear and 
light petticoats. 

TREATMENT. 

Several difficulties are to be met in treating lateral curvature. As 
the affection is active during the period of growth, treatment, to be 
efficient, must be carried on for a long time, and is tedious to the sur- 
geon and irksome to the patient. Furthermore, as the disease is one 
that does not threaten life and is slow and uncertain in its outcome, it is 
sometimes difficult to enforce the proper treatment for the requisite 
length of time. Again, danger of increasing deformity varies at differ- 
ent periods of the trouble, and consequently methods which are neces- 
sary at certain stages of the affection are not needed at others. Cases 
will be brought to the surgeon's care presenting varying degrees of 
deformity and needing different grades of treatment. Cases, how- 
ever, can be grouped in two classes : 

I. Those with slight structural change and curves in the main flexi- 
ble. The treatment of this class is directed to improving the patient's 
attitude, in the expectation that if faulty attitudes are rarely or never 
assumed there will be no danger of an increase in the structural changes 
of the curve. The treatment is <t\\hex postural, directed to the forming 
of correct habitual attitudes ; or gymnastic, directed to strengthening 
weak muscles and thereby favoring correct carriage. 

II. Those with structural change and curves which are fixed. In 
these cases corrective treatment is directed primarily toward correcting 
existing curves. 

I. Treatment of Flexible Cases. 

Postural Treatment. — The postural treatment consists in the cor- 
rection of faulty habits, the development of weak muscles, and the re- 
tention of proper attitudes. As a raw recruit is taught the position 
and carriage of the soldier, so children, if faulty habits of attitude are 
present, are to be drilled into standing and walking in correct attitudes. 
This method is suited for the simplest cases of beginning curvature. 
To be thoroughly carried out, it requires that the patient should daily 
be exercised in walking, standing, and sitting properly for a specified 
time under the direction of some competent person. The principles of 




35^ ORTHOPEDIC SURGERY. 

the " setting-up " drill of recruits in all armies are applicable, with mod- 
ifications, to patients of this class. When resting during the hour of 
drill the patient should remain recumbent. After the drill is over, such 
precaution should be taken as will prevent the persistence for any 

length of time of a faulty attitude. This 
should not be done (out of the drill time) 
by constant correction, but by the proper 
arrangement of the play hours and a super- 
vision of the chairs when reading and 
studying. Walking, running, and active 
games should be encouraged, while read- 
ing, except in proper position, should be 
discouraged. The treatment is strictly 

Fig. 317. — Seat Elevated on One pOStliral. 

Side for Changing Lumbar The usual ba( j habits Q f pos i t j on are as 

Curves. , . . 

follows : standing on one leg, sitting at too 
"low a table, sitting in a twisted position, and sleeping always on one 
;side with too high a pillow for the head. 

Gymnastics. — In many early cases the faulty attitudes are clearly 
the result of muscular weakness. The increase in height has not been 
accompanied by a corresponding development in muscle. This condi- 
tion is frequently met in rapidly growing children, and is one of the 
most common causes of lateral curvature. Here proper gymnastics are 
indicated, but they should be prescribed and carried out with much 
care. In the more marked cases the children are unable to bear much 
exercise without fatigue. Those exercises, therefore, chiefly needed in 
correcting the deformity should be the only ones prescribed. The 
usual class-work of gymnasium is to be avoided, as such cases require 
the individual attention of a competent person, who will see that no 
faulty position is taken during the exercises. 

Each case may be regarded as far as exercises are concerned as a 
separate problem to be worked out individually. 

Light Gymnastics. — It is not a difficult matter to devise simple 
and practicable exercises to develop the muscles chiefly at fault, viz., 
the muscles of the back and loins. The strength of a patient's back 
muscles can be determined in a ready way by attaching a cord to the 
front of a cap tied to the head, and fastening this cord to a spring bal- 
ance. The patient, seated and strapped to a seat at the proper distance 
from the spring balance, held firmly by an assistant, is directed to bend 
backward, keeping the back straight so far as is possible. This exer- 
cise is repeated as many times as advisable. 

The patient stands with the heels, back, and occiput against a pro- 
jecting corner (of furniture or doorway), and places the elbows (the 
.arms being flexed) as far back as possible. 



LATERAL CURVATURE OF THE SPLNE. 357 

The patient, seated on a stool or chair, should place the feet behind, 
and on the inner side of, the front legs of the chair, and slowly bend 
sideways; the assistant, resisting on the head, determines the strain on 
the muscles of either side. 

General developmental exercises for the back, shoulders, and abdo- 
men, when taken with the spine straight and the carriage of the body 
correct, constitute the best general scheme for the treatment of such 
cases. 

Cases will be seen of such feeble muscular strength that it is advis- 
able to begin with those which demand the least muscular effort in 




Fig. 318.— Trunk Bending Apparatus, Raising the Weight and Localizing the Movement. 

(Schulthess.) 

maintaining a symmetrical attitude. For these cases exercises with the 
patient recumbent are desirable, such as the following: 

1. The patient lies upon the back with arms at the side, the feet are 
held, and the patient raises the head and chest. 

2. The patient lies on the face and raises the head and chest. 

3. The patient takes 1 and 2 with the arms behind the head and the 
elbows squared back. 

4. The patient lies on the face with the trunk projecting over the 
edge of a table and the hands on the hip, and raises the trunk to a hori- 
zontal position. 



35§ ORTHOPEDIC SURGERY. 

The same exercises, if repeated with the arms extended above the 
head, require more muscular effort. 

If the patient has gained sufficient strength, a series of light dumb- 
bell exercises with bells weighing from one to five pounds can be pre- 
scribed, carried on with the patient recumbent, similar to those just 
mentioned. Care should be taken that they are correctly performed. 

After this, follow light symmetrical dumbbell exercises with the 
patient standing in a correct position. The work of the patient should 
be tabulated and carefully graded. This is to be followed by heavier 
work of the same general type. 

Heavy Gymnastics. — The method of muscular development by 
means of the use of heavy weights has been employed with advantage 
in cases of scoliosis. This was first thoroughly carried out by Tesch- 
ner, of New York, 1 and in many cases has been followed by excellent 
results. 

The patient should exercise daily with light dumbbells weighing 
from one-half to five pounds, and three times a week exercises under 
supervision with heavier weights should be taken. The weight of these 
heavy bars and bells and the amount of the exercise depend upon the 
strength, capacity, and endurance of the individual. Each patient is 
put to his limit of work at each visit, and this limit is extended at each 
visit. This increase is largely dependent on correctness of posture and 
precision in the work. 

Bells weighing from five pounds to twenty and thirty pounds each 
and steel bars and bar-bells weighing twenty-six pounds and upward 
can be used. The exercises are as follows : 

Bells are pushed from the shoulders above the head alternately as 
often as the patient's strength permits. The patient swings a heavy 
bell with one hand from the floor, above the head and down again, the 
elbow and wrist being fixed and the motion repeated as often as possi- 
ble in a systematic manner; then with the other hand the same number 
of times, and later with both hands. This exerts all the extensor mus- 
cles from the toes to the head in rapid succession. 

When a heavy ball is pushed or swung above the head on the side 
opposite the scoliosis, the action of the back muscles is such as to cause 
the curved spine to approximate a straight line. A similar result is 
produced when a heavy weight is held by the side of the erect body on 
the scoliotic side, the arm being at full length. 

When a heavy bar is raised above the head with both hands, the 
patient must fix the eyes upon the middle of the bar to maintain the 
equilibrium. This necessitates the bending of the head backward, the 
straightening and hyperextencling of the spine, and consequently cor- 

1 Annals of Surgery, August, 1895; Orth. Trans., vol. ix. — Erich: N. Y. Med 
Journal, October 7th, 1899. 



LATERAL CURVATURE OF THE SPINE. 



359 



recting a faulty position with a weight superimposed. The heavier the 
weight put above the head, whether with one hand or with two, the 
more the patient must exert himself to attain and maintain a correct or 
an improved attitude in order to sustain the equilibrium. 

When a patient lying supine upon the floor raises a heavy bar 
above the head so that the arms are perpendicular to the floor, the 
weight of the bar, the position and weight of the body, and the action 
of the muscles tend to broaden the entire back and shoulders, and a 




Fig. 319. — Paper Jacket. Hinged. (Weigel.) 



slow downward movement tends to widen the entire chest, and most 
markedly the shoulders. Pushing the bells above the head, swinging 
them with each hand and with both hands together, raising a bar above 
the head standing and lying clown, and the exercises above enumerated 
constitute a day's work. 

Whether light or heavy exercises are used, persistence is necessary 
for success. It is needless to add that the patient should exercise 
under careful supervision, rest being prescribed as a part of the daily 
treatment, the amount of work being regulated each day. 



360 ORTHOPEDIC SURGERY. 

Asymmetrical Gymnastic Exercises. — Exercises formulated with 
the expectation of isolating certain weak muscles in the back will, as a 
rule, be found impracticable, for the reason that it is difficult to deter- 
mine the weakness of any individual muscle, and because in a lateral 
curve it is difficult if not impossible to exercise a weak muscle on the 
convexity of a curve without the danger of exercising also the strong 
muscle of the compensatory curve. As a rule, symmetrical muscular 
exercises with the body held as symmetrically as possible are the most 
practicable in lateral curvature. A few asymmetrical ones may be used 
if marked difference in the strength of one arm or leg is present, and 
an increased amount of work can be given to the weaker limb or side. 

Fixation Appliances. — It is manifest that during the formative period 
of growth faulty attitudes are to be avoided. Recumbency being inap- 
plicable for a long period, and gymnastics being possible only for a lim- 
ited portion of the day, some form of appliance which checks faulty 
positions is often desirable. 

Corsets made of plaster-of-Paris, leather, paper, and celluloid, or 
cloth stiffened with steel, act as supports and limit faulty positions. 
Weakening of the muscles from the use of such appliances must be 
combated by systematic gymnastics. These appliances should be re- 
movable if designed simply as means of preventing faulty attitudes, 
and are made in the same way as removable corsets for the convales- 
cent stage of Pott's disease, except that they are modelled to correct 
certain positions and not to fix the spinal column. In general, support 
of this sort is indicated when the patient shows no marked improve- 
ment under gymnastic work, but drops back after each exercise period. 
It is evident that under these conditions no satisfactory progress will 
be made without support. 

When side inclination of the trunk exists to such an extent as to 
make the lumbar curve the chief curvature, raising the pelvis (by plac- 
ing an increased thickness under the sole of the shoe on the apparently 
lower hip, and a pad under the lower buttock in sitting) will serve as 
partial correction. 

II. Treatment of Structural Cases. 

Corrective Measures. — When shortened ligaments and muscles are 
situated so that they serve as a check to the free movement of the 
spine, purely muscular exercises are not sufficient for corrective stretch- 
ing. Gymnastics alone are therefore inadequate as a system of treat- 
ment in cases of this class, although useful as an adjuvant and as a pre- 
vention of relapse after correction by other means. It has been proved 
by clinical experience and by experiments on cadavers that pressure 
upon certain parts of the thorax — that is, on the ribs— is effective in 
correcting the distortion of the spinal column in such structural cases. 



LATERAL CURVATURE OE THE SPINE. 36 r 

This corrective force needs to be adequately and correctly applied, and 
is analogous in its aim to the repeated correction used by those train- 
ing themselves to become contortionists or dancers. 

It is also true that bending the trunk to the side by force moder- 
ately applied will often place the spine in an improved and corrected 
position. Such procedures as these increase the flexibility of the spinal 
column in the desired direction and make improved attitude possible. 
It is manifest, however, that if a corrective force is to be beneficial in 
scoliosis it must be made effective on the curved and not on the normal 
portion of the spine. The spinal column above and below the curved 
part where the corrective force is to be applied must be secured ; oth- 
erwise the more flexible and normal part of the spine will be more 
affected by the corrective force than will the abnormally rigid, curved, 
and twisted part. This is true not only of corrective force applied by 
pressure, but of attempts to correct the curve by posture and exercises 
which have as their aim the stretching of shortened ligaments. 

Pressure to the ribs for this purpose should be applied as near their 
attachment as possible, in order to spend as much of the force as possi- 
ble in correcting the deviation of the spine and as little as possible in 
bending the ribs on the spine. 

Corrective measures are either applied intermittently in the milder 
cases or continuously in the more resistant cases. 

Intermittent Correction by Exercises. — These can be given 
with much precision by means of elaborate appliances devised for the 
purpose, of which those used by Schulthess are the best. Simpler 
forms can be employed with benefit if care is exercised in localizing 
carefully the correcting force. These involve some mechanical restraint 
of a portion of the patient's trunk and swinging or stretching the rest 
of the trunk in a direction to straighten the curve. Great care is nec- 
essary in these exercises, which are flexibility exercises and not prima- 
rily designed to strengthen the muscles. There is a danger of increas- 
ing the flexibility of the wrong portion of the column and increasing 
the compensatory curves. A few exercises of this type may be men- 
tioned. Any loss or impairment of spine flexibility, local or general, 
should be remedied, as a normal flexibility in all directions is an im- 
portant matter. Symmetrical stretching is of use in such cases. As 
examples of this may be mentioned : 

1 . Hanging by the arms or suspension by the head in a Sayre sling. 

2. The patient stands with the head and shoulders in a Sayre sling; 
the feet are fastened to the floor, and the patient rotates the trunk 
through a circle, first in one direction and then in the other. 

3. Sitting or standing, the patient rotates the trunk from right to 
left, and then from left to right. 

4. The patient hangs from a bar and by a muscular effort rotates the 



362 



ORTHOPEDIC SURGERY. 



pelvis and legs, first in one direction and then in the other. This ex- 
ercise should be done with some force. 

If round shoulders, contracted chest, or pronated feet coexist with 
the lateral curve, suitable exercises should be added. 

As examples of asymmetrical exercises to increase flexibility, the fol- 
lowing may be men- 
tioned : 

1 . The patient sits 
or stands with the legs 
apart and bends to the 
side of the convexity 
of the curve, or, with 
the arm of the concave 
side across the top of 
the head and the arm 
of the convex side 
around in front of the 
abdomen, the patient 
bends to the convex 
side through the ribs 
and not through the 
waist. 

2. The patient lies 
on the face with the 
feet held. With the 
hands behind the head 
and the elbows raised, 
the body is raised and 
swayed toward the 
convex side, the pa- 
tient trying to " puck- 
er in " the bulging 
ribs and not to bend 
in the lumbar con- 
cavity. 

3. The patient 
stands with the convex 
side leaning against 

a table or a padded roll, and bends over the 




FIG. 320.— Apparatus to Afford Resistance to the Left Shoul- 
der, which Pushes to the Left Against the Pad Raising the 
Weight on the Right Side of the Apparatus, The pelvis is 
fixed. (Schulthess.) 



the padded edge of 

pad which presses against the convexity. 

4. The patient stands with the feet apart and, in a right dorsal, left 
lumbar curve, the right hand is placed against the convexity on the 
ribs with the elbow out from the side, and the left arm on top of the 
head or on the left side of the pelvis, according to the position which 



LATERAL CURVATURE OF THE SPLNE. 



363 



seems to give the best correction. The right hand then presses the 
convexity to the left, using as much force as possible. 




Fig. 321.— Apparatus for the Forcible Correction of Lateral Curvature in Suspension. 

(Weigel.) 

5. Remembering that a twist to the right causes a left lateral curve, 
beginning below above the lumbar region, a twist to the right may be 



364 



ORTHOPEDIC SURGERY. 



used as an exercise for antagonizing a curve to the right in that region. 
The patient sits back to the surgeon, the hands behind the head and 
the elbows squared back, and, while the pelvis is held, twists the head 
and shoulders as far to the right as possible. , 

The variations to be made in these exercises are many, but compli- 
cated exercises are undesirable, as it is not possible to analyze their 
anatomical effect, and the risk necessarily involved in asymmetrical 
work of inducing or increasing compensatory curves is increased. 

Such exercises should be given with great care, with the back 

exposed to view as a rule, and should 
be followed by a period of rest. In 
order to make such exercises effective 
in the spine the pelvis should in all 
cases be fixed during the exercises. 

The rules for the simultaneous 
use of supporting appliances are the 
same as those given in speaking of 
flexible curves. 

Intermittent Stretching by 
Appliances. — Intermittent correc- 
tive force may be applied passively 
for stretching at frequent periods 
by means of appliances to be men- 
tioned in speaking of the use of cor- 
rective jackets. This procedure is 
advisable when free standing or 
other exercises need to be reinforced 
temporarily by more accurately local- 
ized stretching. The same procedure 
is advisable in many cases as a pre- 
liminary to the application of cor- 
rective jackets, in order to obtain 
beforehand greater flexibility in the 
direction of correction. 
Corrective Measures — Continuous Use of Force. — In certain cases 
the curves are too resistant to be altered materially by intermittent cor- 
rection. In suitable cases attempts can be made to correct the curves 
by a method of constant pressure, as it has been demonstrated that the 
shape of bone is altered by constant pressure. This is shown not only 
in dentistry in the success in altering the shape of the jaw, in the cor- 
rection of congenital club-foot with congenital bone changes, but also 
pathologically in the artificial development of structural changes in 
bone seen in the Chinese lady's foot, 1 Wullstein's experiments in the 
1 P. Brown: Journal Med. Research, December, 1903. 




FiG. 322.— Corrective Plaster Jacket with 
Head-piece Applied for the Correction 
of Scoliosis. (Wullstein.) 



LATERAL CURVATURE OF THE SPINE. 



36; 



artificial development of lateral curvature already mentioned, in the pro- 
duction of lateral curvature in different occupations, 1 and in the altera- 
tion of the jaw from scar contraction after burns and the alteration of 
the shape of the face in torticollis. For the application of this method, 
plaster jackets should be applied to the patient in a corrected or over- 
corrected position. 

It is evident that this method of correction is chiefly applicable dur- 
ing the growing period. * 

Corrective plaster jackets can be applied, as for caries of the spine, 
with the patient in a standing or sitting position or recumbent, either 
lying on the face or back. Jackets are applied as for caries of the 
spine, but much more skill is required, as the amount of correcting force 
and method of applying require the exercise of judgment. If a good 





FIG. 323.— Diagram of Plaster Jacket. 



FIG. 324.— Slipping of Plaster Jacket. 



deal of force is employed, the patient may be exposed to subsequent 
discomfort. It is usually preferable to use correcting force without an 
anaesthetic and apply jackets at short intervals. 

Suspension or a traction force is manifestly of less value than in 
caries of the spine, as the affected portion of the spine in lateral curva- 
ture is always the most resistant portion, while in caries the curve, if 
in a stage suitable for treatment, is less resistant. The most economi- 
cal application of force in straightening a stiffly curved stick is by 
bending it over a resistant pressure rather than by pulling each end. 
Experiments on cadavers show that this is applicable to the human 
trunk. 2 

If the patient is seated or standing, a head sling will be of assistance, 
with some suspension force to steady the upper part of the trunk. 
Traction force may be used in the recumbent position, though it is 
rarely needed. 

1 Lane: Guy's Hospital Reports, xxviii. 

- Lovett: American Journal of Anatomy, 1904. 



366 ORTHOPEDIC SURGERY. 

The relative advantages of the different positions of the patient in 
the application of a corrective jacket are as follows : 

With the patient standing or seated it is much easier to apply the 
bandage on all sides of the patient than when the patient is recumbent, 
and for this reason is preferable in applying jackets to the neck and 
shoulders. In the upright position the position of the head relative to 
the thorax is that usual in locomotion, while in recumbency an altera- 
tion in the normal thorax takes place. Recumbently applied jackets 
are therefore less comfortable to the patients than those applied with 
the patient upright. 

If the patient is seated it is easier to correct lordosis or any torsion 
of the pelvis than if the patient is standing, but in the seated position 




FIG. 325.— Apparatus (Kyphotone) for the Application of Forcible Jackets in Scoliosis 
during Recumbency on the Back. (R. T. Taylor.) 

the surgeon needs to take especial pains in arranging the seat so as to 
enable him to apply a jacket which will hold the pelvis firmly. 

Much greater correcting pressure can be applied with the patient in a 
recumbent position, as the superimposed weight is not an influence to be 
opposed. In recumbency on the face lordosis can be overcome more 
readily than if the patient lies upon the back. It is less easy, however, 
to secure a desirable expansion of the chest and arching backward of 
the spine in the dorsal region in face than in back recumbency. Where 
there is much rotation to be corrected, the recumbent position is to be 
preferred. Where side deviation is the more important feature, the 
upright position is to be considered also. 

The simplest method of application of a corrective jacket is for the 
patient to sit or stand in the centre of a four-upright frame. The 
head is secured in a head sling with moderate traction. Webbing 
straps pass from the different uprights and can be made to exert press- 
ure in different directions as desired. These are included in the jacket, 
the emerging portions being cut off. A more complicated appliance, 
with more precision in the application of the force, is one furnished 



LATERAL CURVATURE OF THE SPINE. $6y 

with circular steel bands connected with the uprights. From these 
adjustable bands screw pressure rods can be made to exert pressure on 
all desired parts of the trunk. 

In the recumbent position the patient may be placed with the back 
supported on a frame with uprights similar to that used in the applica- 
tion of corrective jackets in Pott's disease, except that the pressure 
points are applied in the back, not upon the transverse processes, but 
upon the backward prominence of the ribs. Correction of lateral devi- 
ation can be furnished by horizontal traction, if necessary, or by side 
pressure. Felt padding is needed over the portions of the body which 




Fig. 326.— Apparatus for the Application of Plaster Jackets during Recumbency on the Face. 

are but little protected by fatty tissue ; the plaster bandages should be 
applied high up under the drooping shoulder and over the shoulder 
from behind, across the neck. When the plaster is sufficiently hard- 
ened the patient can be lifted, the detachable plates which are thor- 
oughly padded remaining in the jacket. 

A simple method of application of a corrective jacket in an inclined 
or recumbent position is to secure the patient firmly in the centre of 
the four-upright frame used for applying a jacket in the upright posi- 
tion and inclining the whole frame backward. The correcting straps 
will need readjustment for proper correcting force when the patient 
is changed from the upright to the recumbent position. 

An effective appliance for corrective jackets in face recumbency is 
in use at the Boston Children's Hospital, devised by Dr. Z. B. Adams. 
The apparatus consists of a heavy gas-pipe frame, three by four feet. 
The patient lies face downward on two webbing strips, running from 
end to end of the frame, with the legs flexed. Near the bottom of the 
frame is an adjustable crossbar bent to fit into the flexure between the 



3 68 



ORTHOPEDIC SURGERY. 



thighs and the pelvis, on which the patient rests the lower part of the 
body. Sliding on thh bar are two arms, which slide in and clamp down 
on the buttocks, holding the pelvis steady on the crossbar. This bar 




is movable from side to side in order to induce or correct curvature in 
the lumbar region when necessary. There are three vertical transverse 
rings, two feet in diameter, fastened to pieces on the sides of the frame 



LATERAL CURVATURE OE THE SPINE. 



369 



so that they can be moved to any desired point along the frame. These 
rings are also movable from side to side, and by an independent move- 
ment they can also be rotated through a half circle. Any one of these 
movements can be checked at any point by turning a screw. The 
shoulders are held by a pair of axillary straps fastened together by a 




strap across the chest in front. These straps are suspended from the 
ring nearest to the top of the frame and can be made to hold the shoul- 
ders in any desired degree of twist by a rotation of the ring. 

Each ring is provided with two long screws at the two poles of the 
ring. These screws are adjustable upon the ring and can be set at any 
desired angle to it. By rotating the ring and adjusting the angle of the 



370 ORTHOPEDIC SURGERY, 

screws they can be made to screw down or up upon any part of the 
back or chest. 

For the application of the jacket the patient lies on the face on the 
two webbing strips, the lower part of the trunk resting on the cross rod 
and the bars clamping the buttocks ; the feet rest on the floor and the 
arms are extended above the head. The rings are then adjusted at the 
two levels where it is desired, to make correction, generally in the dorso- 
lumbar and the dorsal regions. For side correction a webbing strap is 
fastened to one side of the ring, carried around the patient's side over 



/ 




Si 





FIG. 329.— Lateral Curvature Before FlG. 330.— Lateral Curvature Three 

Correction. Weeks After Correction. 

a heavy pad of felt and back to the ring. The same is done to the 
other ring at the other level where side correction is desired, while the 
top ring controls the shoulders. The rings are then pulled to one side, 
the bandages around the patient tighten, and any endurable degree of 
side correction is obtained. 

When the side correction is made the screws are then screwed down 
on to the patient, their points being protected by sheet-iron pads, two 
by three inches, which are covered with heavy felt. These pads are 
incorporated in the jacket. 

The shoulders are controlled by the axillary pads attached to the 
upper ring along with screw pressure up or down as desired. In the 
correction each level is separately attacked from below upward. 



LATERAL CURVATURE OF THE SPLNE. 371 

A plaster jacket is applied to the patient held in this way with a 
great amount of force at the operator's disposal. 

In applying corrective jackets it is to be remembered that there are 
two elements of the deformity demanding correction — one, the lateral 
curve, to be corrected by side force; the other, the rotation, to be cor- 
rected by a twisting force. Any use of force, to be effective, must be 




Fig. 331.— Case of Scoliosis before Operation Showing Lateral Deviation of Spine. 

(Michael Hoke.) 

met by counter-points of resistance or the whole spine will be pushed 
to one side or twisted as a whole. 

High dorsal curves are not likely to be much improved by correc- 
tive jackets, because no satisfactory point of counter-pressure can be 
found above the curve. Lumbar curves are also generally better 
treated by other means, because there are no ribs to exert side pressure 
on this region and direct side force cannot be exerted. 



372 ORTHOPEDIC SURGERY. 

Corrective plaster jackets should embrace the shoulders and, in 
cases of high dorsal curves, the neck, and should not be removable. 
Windows can be cut in the jacket over the portion of the trunk where 
pressure is undesirable. At first the patient will need supervision, 
but later can go about freely. Jackets should be repeated at short 
intervals, preferably two or three weeks, and applied as long as cor- 




FlG. 332.— Case of Scoliosis Before Operation Showing- Rotation. (Michael Hoke.) 

rection can be obtained. This stage of treatment is followed by that of 
removable jackets and gymnastic exercise. 

The amount of correcting force used is a matter of judgment, as is 
also the time when corrective pressure treatment should be discontin- 
ued. Supporting jackets are necessary for many months after correc- 
tion has stopped, and should be discontinued gradually. 

Adult Cases. — When the bones have become hardened by growth, 
marked correction is not possible either by intermittent or by constant 
pressure. The treatment must be palliative and consist of gymnastics, 
massage or electricity to relieve symptoms, accompanied or not, ac- 



LATERAL CURVATURE OE THE SPINE. 



373 



cording to circumstances, by corsets as a partial support to superim- 
posed weight. 

Treatment by Operation. 

Operative attempts consisting of resection of the projecting ribs, 
performed by Volkmann in 1889 and Hoffa 1 in a few instances, have 
been made in cases in which the distortion of the ribs resulting from 



'^V *■* 





s*- 




H 



Fig. 333. — Case of Scoliosis After Operation. (Michael Hoke.) 

rotation is so severe as to preclude the possibility of correction by 
other means. The success obtained was not great. 

Hoke 2 has utilized this method, carefully executed, as a preliminary 
to later jacket correction, on the theory that in some cases with marked 
distortion of the thorax the ribs constitute an impediment to correction 
of the rotation. The success obtained by Hoke was satisfactory in the 
case in which the treatment was reported. 

1 Zeitsch. f. orth. Chir., 1896. 401. 

' 2 Amer. Jour, of Orthop. Surgery, vol. i., No. 2. 



374 ORTHOPEDIC SURGERY. 

Braces and Corsets. — Treatment by the use of spinal braces and 
spinal corsets alone, other than the temporary use of plaster jackets 
applied under corrective pressure, is not advisable. These serve only 
as an adjuvant to other treatment. 

Summary of Treatment. ' 

If the back is flexible and no observable osseous change has taken 
place and the curvature disappears during suspension or recumbency, 
the treatment should be postural and gymnastic. The gymnastics 
should as a rule be "light," symmetrical work. Asymmetrical exer 
-rises may form a subordinate part of the treatment. Corsets are 
needed in the more marked cases where exercises alone do not effect 
improvement. 

When the curve is somewhat fixed but fair flexibility remains, the 
treatment should consist of corrective stretching by gymnastics or 
appliances and heavy and light symmetrical gymnastics. Supports will 
be required under the same cenditions as those mentioned for flexible 
cases. 

In structural cases with rigid curves, gymnastics are of use only as 
an adjuvant, and corrective foi,"e intermittently exerted by appliances 
and gymnastics or continuously exerted by means of corrective jackets 
are the modes of treatment to e considered. The latter is the proper 
method for the severer cases. G evere structural cases have been oper- 
ated upon with fair success. Severe structural cases in adults are best 
treated by support, massage, and exercises to secure a better general 
carriage. 

The length of time needed for treatment varies necessarily. In 
general it may be stated that growing children with a tendency to 
faulty attitude need careful inspection during the years of growth. 
The inspection need not be frequent, and will vary from three months 
to six months according to the rate of growth. In light cases a few 
weeks' supervision of gymnastics, followed by monthly or quarterly in- 
spection, is all that is necessary. In severer cases the treatment will 
require at first frequent attendance and later, observation for a period 
of months followed by inspectbn at longer intervals. 



CHAPTER XII. 

OTHER DEFORMITIES OF THE SPINE AND 
THORAX. 

Kyphosis (Round shoulders. — Causes. — Symptoms.— Prognosis.— Treatment). — 
Lordosis.— Spondylolisthesis (Pathology. — Etiology. — Symptoms. — Treat- 
ment). — Deforjpiii r eon Breast. — Funnel Chest. — Con- 

n of the Scapula. 

th't and does not present the 

i. 

6 the child attempts to sit and 
the others in that it can be 
of the head, while the other 
at least, permanent. 

p habits, occupation, muscular 

:. The normal curves are for- 
the dorsal, and forward in the 



le are set by the shape of the 

nd the tonicity of the muscles. 

>eruse, by too rapid growth, or 

ghly to do the work expected 

these curves. The spine is 

position, 1 and the amount of 

to the accompanying table of 

;ople standing, and their length 

s ; ten of these were adults and 

latively greatest in the child. 













jec, 


Length in Dorsal " 
Recumbency. 


Difference. 




n. 


5 ft. 


9} in- 


if in. 












\ 




6 " 

5 '' 


2 T6" 

8tV " 


16 










3 
T~5 


' 




5 " 


IlV " 


1 4 k . 

16 










8 


' 




5 


o; a 
°T6 


10 t< 

15" 








Q 1 2 

6 T 6" 


• 




5 " 


9 " 








J 


" 


Ul4 


. 




6 " 


■1 a 
16 


1* 




_ 


s 


i . 


"tV 


' 




5 '" 


"tI " 


4 a 


9 


! 3i 


6 


" 


2 






6 '• 


2 16 


1A " 

1 6 


10 




5 

3 




4t# 

i tV 


k 




5 kt 
3 " 


5x6 " 




ii 


o1 








H " 









T. A. Storey: Am. Phys. Education Review, 1904. 

375 



376 



ORTHOPEDIC SURGERY. 



The term kyphosis is used to designate an increase in the backward 
dorsal physiological curve, and the term lordosis to describe an increase 
in the forward physiological curve in the lumbar region. 



KYPHOSIS. 



An increase of the backward curvature of the spine, being an exag- 
geration of the dorsal curve, is most noticeable in the upper part of the 
spine, although it may practically involve the whole column. It occurs 




Fig. 334.— Round Shoulders. Curve of 
dorsal and lumbar regions. Marked 
forward displacement of shoulder. 



(1) as a static deformity, whic'.i is the commonest form seen, and is 
known as " round shoulders " ; or (2) as the result of an abnormal con- 
dition of the bones or as a result of paralysis. 



OTHER DEFORMITIES OF SPINE AND THORAX. 377 



i. Round Shoulders. 

The term round shoulders is generally applied to the stooping atti- 
tude which results from the muscular relaxation due to rapid growth, 
to the assumption of improper attitudes, and to poor general condition. 





FIG. 336. — Round Shoulders with Forward Dis- 
placement of Scapulae. Back comparatively 
fiat. 



Fig. 337. — Round Shoulders with 
Increased Lumbar Lordosis. 



It is generally seen in children and is likely to be observed at any time 
after the age of five or thereabouts. 

Causes. — The affection is to be regarded as a static one connected 
with improper muscular support. The common causes are as follows: 

Improper position at school and at home. The stooping position 
necessitated by improperly fitted school furniture used, by the attitude 
assumed in writing, and the curled-up position assumed by children in 
reading at home are important factors in the causation of round shoulders, 
and what has been said in regard to the causation of school scoliosis 
applies equally well to round shoulders. 

Rapid growth, long hours at school, 



insufficient food, improper 



378 



ORTHOPEDIC SURGERY. 



arrangement of clothing, and too long an active day are causes inducing 
muscular debility and therefore favoring round shoulders. 

Symptoms. — The attitude of round shoulders is well known and the 
name itself is descriptive. The head is not carried erect, but is run 
forward somewhat, the shoulders slope forward, the scapulae are unduly 




FIG. 338.— Sitting Position in Marked Round Shoulders. The spine is flexible and can be 
straightened by muscular effort. 

prominent behind and may be noticed through the clothing in severe 
cases, and the whole shoulder-joint seems to be forward of its normal 
position, the chest is narrow and flattened, and the expansion deficient. 
The lumbar spine may present an increased forward curvature, so that 
the patient stands with an abnormally hollow back, or the lumbar spine 
may be involved in the backward curve and the lumbar curve dimin- 
ished or lost. The patient's trunk is carried back and the abdomen 
thrust forward. The pelvis is forward of its normal position. Some 
degree of flat-foot is likely to coexist, and beginning lateral curvature 
accompanies many of the cases. 

With the persistence of the attitude of round shoulders the muscles 
and ligaments in front of the shoulders become shortened and those at 
the back stretched. The muscular development is generally poor. If 



OTHER DEFORMITIES OF SPIKE AND THORAX. 379 

the arms are carried to a vertical position above the head, it is done by 
arching the spine forward in the lumbar region, which is made neces- 
sary by the contraction of the muscles connecting the arms and upper 
chest, such as the pectoral muscles. Pain is not often complained of, 
but may be present in nervous children, especially girls. 

The attitude maybe partially corrected temporarily by the voluntary 
muscular effort of the patient, but the faulty attitude will be again 
assumed almost immediately, as the muscles are unable to maintain the 
corrected position. 

The types of variation in the physiological curves of the spine are 
described 1 under four heads: 1. Flat back. 2. Flat hollow back. 3. 
Round back. 4. Round hollow back. The first two are rather indi- 
vidual variations from the normal of no especial significance, and will 
be understood from the figures. The last two are the two variations 
roughly grouped as round shoulders. 

Prognosis. — The prognosis without treatment is not good, so far as 
recovery from the deformity is concerned, and it may be carried over 
into adult life practically unchanged. With proper treatment recovery 
is to be expected. 

Treatment. — In the treatment of round shoulders the patient should, 
of course, be put in the most favorable surroundings possible. Incorrect 







Fig. 339. Fig. 340. Fig. 341. Fig. 342. 

Round Back. Round Hollow Back. Flat Hollow Back. Flat Back. 

(Modified from Staff el to show only upper part of figure.) 

attitudes at school and at home should be corrected so far as possible. 
Errors in vision are to be investigated and remedied if they exist. Undue 
fatigue and a very long active day are to be avoided. 



1 Staffell: "Die mensch. Haltungstypen," etc., Wiesbaden, 1889. — See Lovett : 
" Round Shoulders," etc. (with literature). Boston Med. and Surg. Journ., 
November 6th, 1902. 



380 ORTHOPEDIC SURGERY. 

Arrangement of Clothing. — It is a common custom to fasten 
a child's clothes, including the garters, to a waist which is kept from 
slipping down by two straps over the shoulders. These straps do not 
pass over the root of the neck, but most often over the tips of the 
shoulders, where they obtain increased leverage to pull the shoulders 




Fig. 343.— Deformity of Shoulders due to the Pressure of Cervical Ribs. (Dr. C. F. Painter.) 

downward and forward. The constant drag of this not inconsiderable 
weight upon structures little suited to support it is a most important 
factor. The arrangement of clothing should be improved and round 
garters should be worn, and the stockings should not be fastened to 
the waist. The trousers and skirts should, if possible, be supported 
by a belt, and the waist to which the clothes are ordinarily fastened 
should be relieved of as much weight as possible. The shoulder 
pieces of the waist should consist of two straps passing close to the 
root of the neck and not running over the tips of the shoulders. In 
this way the constant drag of the clothing upon the tips of the 
shoulders will be avoided. In the more marked cases it is some- 
times advisable to use a support of firm webbing, one inch wide, which 
runs transversely across the back at the level of the axillary line, passes 



OTHER DEFORMITIES OF SPINE AND THORAX, 38 I 

through the axilla on each side, and over the front of the shoulders, 
crossing diagonally in the middle of the back. These straps should be 
sewed where they cross in the back. To the bottom of these straps 
may be fastened the clothes, if necessary, and their weight will serve 
in a measure as a somewhat corrective backward pull. 1 

Gymnastics. — The gymnastic treatment of round shoulders con- 
sists in stretching the contracted tissues and in drilling the child in the 
maintenance of a correct position. The stretching can usually be 
accomplished by simple measures. Suitable exercises for this purpose 
are as follows : • 

1. The patient hangs from a bar by the arms. 

2. The patient lies on the back with a hard roll under the scapulae, 
while the arms are extended and stretched by an assistant pulling 
them above the head upward and backward. 

3. The patient sits on a stool with the hands behind the head and 
the elbows squared, and the elbows are pulled backward while the knee 




FIG. 344.— Schulthess' Apparatus for Correction of Round Shoulders. (Schulthess.) 



of the manipulator presses forward against the spine on a level with the 
shoulders. 

The restoration of flexibility before giving corrective work is essen- 
tial. The use of a greater degree of force is sometimes necessary to 
accomplish the desired stretching. This may be accomplished by the 
] J. E. Goldthwaite : Amer. Jour, of Orth. Surg., vol. i., No. 1, p. 65. 



3 82 



ORTHOPEDIC SURGERY. 



application of plaster jackets 1 covering the shoulders and pulling the 
shoulders back with any desired degree of force, or by any form of 
stretching apparatus which pushes the dorsal region forward while 
holding the shoulders back. As soon as flexibility is restored, postural 
light gymnastic work directed to the muscles which it is desired to de- 




FlG. 345.— Apparatus for .Stretching of Round Shoulders. 



velop should follow. The demands of the cases are not essentially dif- 
ferent from those of early scoliosis so far as the gymnastic treatment 
goes, the object in each case being to cultivate a correct attitude. 

Apparatus (Chapter XXI., 22). — -In cases of marked round shoul- 
ders, when the children are unable to maintain for any length of time 
a corrected position, some mechanical assistance to the extensor mus- 
cles is needed. A useful brace consists of a posterior horizontal pelvic 
band, grasping the pelvis at the level of the anterior superior spines. 
From this run up, at a distance of one inch or less from the spinous 
processes, two tempered steel uprights, which are turned out on the 
flat at their upper ends and terminate just below the root of the neck 
well toward the axillary line, where they are furnished with an axillary 
straps, which run through the arm-pit and fasten to a transverse cross- 
bar on the brace. This brace is furnished with an abdominal band, 

1 Amer Jour, of Orth. Surg , vol. ii., No. 3. 



OTHER DEFORMITIES OF SPIXE AND THORAX. 383 

which runs from the upright around the abdomen, to assist in the main- 
tenance of the correct position. 

A modification of this brace has been made by Thorndike 1 Chap- 
ter XXI., 23), by adding movable shoulder-pieces, so that the patient 
has a freer use of the arms. 



Static Kyphosis from Occupation. 

This type of deformity occurs in adults and in children. In adults 
it is either the result of a condition acquired in childhood carried over 
into adult life, or it is acquired by some habitual position connected 
with the occupation of the individual. It is also seen in workmen who 
carry heavy loads upon their shoulders. The investigations of W. A. 
Lane ' would seem to indicate that the form of deformity caused by 
occupation is due, not only to a change in muscles and ligaments, but 
to a real alteration in the shape of the bones. In the same way, as has 





fig. 



546. — Patient with Round Shoulders 
Before Stretching. 



FIG. 347.— Patient One Month Later After 
Treatment by Stretching. 



been seen in scoliosis, the persistence of an exaggerated curve of the 
dorsal spine in a growing child would be likely to lead to a structural 
change in the bones, resulting in a permanence of the condition. 
Round shoulders from occupation are noticed in tailors who sit cross- 
legged with the spine bent, cobblers who bend over their work, clerks 

'Practitioner. May. 1901. 



384 ORTHOPEDIC SURGERY. 

who sit continually bent over a desk, and in men performing heavy 
work, such as blacksmiths, who work continually bending over a bench 
or an anvil. The exaggerated curve of the dorsal spine acquired by 
children who bend over their desks at school is also to be classed in a 
measure as an occupation curvature. 

Kyphosis may also occur in (2) Pott's disease, (3) spondylitis defor- 
mans, (4) scoliosis, (5) osteomalacia, (6) rickets, (7) ostitis deformans, 
(8) paralysis of the back muscles, (9) old age, acromegaly, and sec- 
ondary osteoarthropathy. 

LORDOSIS. 

Lordosis is the name applied to the increase of the physiological 
curve forward in the lumbar region. This exists in various abnormal 
conditions, and the amount of curve, of course, varies in normal indi- 
viduals from those who have a very flat back in the lumbar region to 
those who have a very markedly hollow back. In certain cases in 
which the individual is perfectly normal, a very marked lumbar curve 
exists. It is hardly necessary to do more than mention the various 
conditions in which lordosis exists. 

1. Lordosis often exists in connection with the kyphosis of the dor- 
sal spine spoken of in connection with round shoulders ; here it is com- 
pensatory to the dorsal curve and the result of muscular weakness. 

2. Lordosis also exists in pregnant women and often in persons with 
large abdomens, due to accumulation of fat or to distention, as in 
ascites and abdominal tumors. In these cases it is simply the balanc- 
ing of weight by which the centre of gravity is brought over the centre 
of support. 

3. Increased lumbar curve also exists as the result of training in 
professional gymnasts, especially in backward contortionists. Such 
persons habitually walk with a marked degree of lordosis. 

4. In conditions in which the abdominal or the back muscles are 
paralyzed, the attitude of lordosis is the result of an attempt to balance 
the weight of the upper part of the body without bringing a strain upon 
the muscles. In paralysis of the abdominal muscles lordosis exists. 

5. In Pott's disease of the lumbar region apparent lordosis may be 
one of the first symptoms to be noticed. 

6. In cases of double congenital dislocation of the hip lordosis gen- 
erally exists, because the point of support of the femur on the pelvis is 
oftenest back of the acetabulum; consequently the pelvis rotates on a 
transverse axis, carrying the lumbar spine forward. 

7. Lordosis exists in many cases of severe rickets on account of the 
rotation of the pelvis on a transverse axis, as will be described in speak- 
ing of rickets. 



OTHER DEFORMITIES OF SPINE AND THORAX. 385 

8. In hip disease, in which on account of muscular rigidity or ad- 
hesions one leg is held in the position of flexion, lordosis is present. 
In double hip disease with flexion deformity the lordosis may be exten- 
sive. Contraction of the hip, for any reason, as in infantile paralysis, 
causes lordosis. 

9. Lordosis may exist in coxa vara, both secondary to the distortion 
at the hip and as another manifestation of the rhachitic change. 

10. In spondylolisthesis lordosis is very marked. 

Treatment. — The treatment of these curves is necessarily dependent 
upon the causative conditions and attendant circumstances. 



SPONDYLOLISTHESIS. 

The name spondylolisthesis (<ncovduXo$ f a vertebra, and 6h<rdr i (n^ i a 
gliding) refers to a forward subluxation of the body of one of the lower 
lumbar vertebrae, with the exception of one recorded case in which the 
upper part of the sacrum was displaced forward. This displacement 
has ordinarily been described as a dis- 
location; inmost instances it hardly 
reaches a greater degree than may 





PlG. 348.— Small Pelvis of Prague (Median Sec- 
tion). Instance of slight forward displacement 
of fifth lumbar vertebra. (Neugebauer.) 



Fig. 349.— Breslau Specimen. Instance 
of slight forward displacement of 
the fourth lumbar vertebra. (Neu- 
gebauer.) 



be described by the name subluxation. Even this name is incorrect 
anatomically, because the body of the vertebrae is chiefly affected, 
while the laminae and spinous process remain practically in place. 1 

1 Neugebauer: " Spondylolisthesis et Spondylizeme," Paris, G. Steinheil, 1892. 
Critical review, description of specimens and cases, complete bibliography.— Kil- 
lian: "Comment, anat. de Sp.," Bonn, 1853; " Schilderung neuer Beckenformen," 
Mannheim, 1854.— Blake : American Journal of the Medical Sciences, 1867, cvii., 
p. 285.— V. P. Gibney: Medical Record, March 30th. 1SS9.— Lombard : Boston 
Medical and Surgical Journal, August 20th, 1885.— Lovett : Trans. Amer. Orth. 
Assn., 1897. 
25 



3 86 



ORTHOPEDIC SURGERY. 



Pathology. — The essential part of the condition seems to be the 
slipping forward of one of the lower lumbar vertebral bodies, while the 
vertebral arches remain practically in place. This implies, of course, 




FIG. 350. — Pelvis of Moscow (Median Section). 
Instance of extreme forward displacement of 
fifth lumbar vertebra. (Neugebauer.) 




FIG. 351.— Specimen from the Museum 
of Kolliker at Wurzburg, Showing 
Double Defect of Vertebral Arch. 
(Neugebauer.) 



an increase in the distance between the body and the spinous process 
of such a vertebra. 

The commonest form of the displacement is subluxation of the fifth 
lumbar vertebra in relation to the sacrum. The displacement of the 




Fig. 352.— Spondylolisthesis due to Vertebral Disease. (Dr. H. B. Cushing, Johns Hopkins 

Hospital.) 

fourth lumbar vertebra in relation to the fifth is next in frequency. 
The displacement forward of the first sacral vertebra in relation to the 
rest of the sacrum has been recorded once only (H. von Meyer, Zurich 
specimen). The displacement may be slight or extreme. 



OTHER DEFORMITIES OF SPINE AND THORAX, 3$ 7 

Etiology. — Spondylolisthesis is recorded as affecting women more 
frequently than men, and comparatively few male cases have been 
recorded. It occurs almost always at puberty or in young adult life, 
and the majority of all cases give the account of a severe traumatism, 
occurring most often during childhood or near puberty. The deformity 
may follow immediately upon the accident, or it may develop in after- 




FlG. 353.— Case 



of Spondylolisthesis. Woman, thirty years old. (Breisky.) 



years, just after puberty or during pregnancy. Other cases are to be 
accounted for only by frequency of pregnancy or by very hard work. 
In some cases no assignable cause can be found. 

Symptoms. — The symptoms by which the diagnosis must be made 
are as follows : A disturbance of equilibrium resulting in a faulty car- 
riage, which is shown chiefly by a sharp increase in the lower lumbar 
curve in even the mildest cases. The spine curves forward sharply 
from the sacrum, and this gives undue backward prominence to the 
crest of the ilium and the buttocks. The appearance at first glance is 
the same as that in cases of double congenital dislocation of the hip. 
Lateral deviation of the spine may be present. With this lordosis goes 



3 88 



ORTHOPEDIC SURGERY 



a diminution of the obliquity of the pelvis, which causes flexion of the 
thighs. 

Vagina] examination shows, of course, a prominence high up on the 
posterior wall of the pelvis. The trunk is shortened in relation to the 
legs on inspection, and the thorax tends to approach the pelvis. The 
affection is not one characterized by excessive pain. 

The differential diagnosis must be made from Pott's disease, double 
congenital dislocation of the hip, and rickets. Rickets must be recog- 
nized by its general diagnostic signs. 

Treatment. — The most successful treatment consists in fixation of 
the lower spine by a jacket or brace until the fracture, if such has oc- 
curred, has united and the products of the injury have been absorbed; 





Fig. 354. — Side View of Case of Spondyl- 
olisthesis. (Braun v. Fernwald.) 



FIG. 355.— Back View of Same Case. 



or, if heavy weight-bearing has been the cause, until the stretched and 
weakened tissues have resumed as normal a position as possible. This 
period must, of course, last for months, or in cases of great deformity 
it would seem as if a fixation support must be permanent. 



OTHER DEFORMITIES OF SPINE AND THORAX. 3^9 



DEFORMITIES OF THE THORAX. 

Pigeon Breast (chicken breast, Hiihnerbrust, pectus carinatum or 
gallinatum, poitrine en carene, poitrine de pigeon, etc.) is a deformity 
more or less common in children, characterized by a prominence of the 
sternum and cartilages of the ribs and accompanied by an increase in 





FIG. 356. — Traumatic Spondylolisthesis 
in a Young Man of Eighteen. 



Fig. 357.— Funnel Chest. (J. S. Stone.) 



the antero-posterior diameter of the chest and a diminution in the lat- 
eral. The deformity is generally most marked in the median line, but 
in many cases the prominence affects chiefly the ribs of one side, mak- 
ing a unilateral prominence on one side of the sternum. It is due to 
rickets and is associated often with nasal or pharyngeal obstruction in 
growing children. It is also seen in a marked degree in dorsal Pott's 
disease, in which it is due to the sinking forward of the upper dorsal 
spine, carrying with it the ribs. In slight cases the deformity is prob- 
ably outgrown spontaneously, but in the severer cases it may last into 
adult life. 



39° 



ORTHOPEDIC SURGERY. 



The treatment consists in children in a combination of gymnastic 
and respiratory exercises to expand and develop the lateral parts of the 
chest. As a type of these exercises may be mentioned a useful one, in 
which the patient lies on the back and, with strong pressure made 
downward on the deformity, deep inspirations are taken. 

Funnel Chest (funnel breast, Trichterbrust, pectus excavatum, tho- 
rax-en-entonnoir) is a name applied to a deformity in which the sternum 
and costal cartilages are depressed below their normal level. The de- 




FlG. 358.— Congenital Elevation of the Scapula. 

formity is as a rule asymmetrical, and in its lighter degrees is not un- 
common. It is more marked in males than in females, and but little is 
known of the cause of the affection. In many cases it apparently is 
congenital, and in a mild degree is sometimes seen in connection with 
Pott's disease. No satisfactory treatment has been formulated beyond 
general gymnastic measures, among which may be mentioned forced 
inflation of the chest. 

Congenital Deformities. — Other deformities of the thorax of con- 
genital origin need only to be mentioned. Among these are absence or 
a defective formation of the ribs, a condition generally associated with 
lateral curvature of the spine, the presence of cervical ribs, and anomalies 



OTHER DEFORMITIES OF SPINE AND THORAX. 391 

or absence of the pectoral and other muscles. Defective formation or 
absence of the clavicle has been reported, and malformation of the 
scapula is sometimes seen. 

Congenital Elevation of the Scapula (Sprengel's deformity, ange- 
borener Hochstand des Schulterblattes). — This condition is a somewhat 
unusual congenital deformity, in which one scapula is raised in its rela- 
tion to the thorax and clavicle and also to the opposite scapula. The 
scapula is not only raised, but generally so rotated that its lower angle 
approaches the spine. Scoliosis is likely to exist in connection with it, 
and in some cases asymmetry of the face and skull has been noted ; the 
affection is rarely bilateral. 1 One or more of the scapular muscles may 
be absent and bony anomalies are frequent. In one class of cases a 
bridge of bone connects the scapula and the vertebral column ; in an- 
other class there is a long piece of bone projecting upward from the 
superior border of the scapula, but not articulating with or attached to 
the vertebrae. In other cases there is no bony outgrowth and no defi- 
ciency of muscles. In some cases the projecting upper border of the 
scapula is so noticeable in its elevated position that it is mistaken for 
an exostosis. 2 

The etiology is obscure. Certain of the cases are evidently to be 
classed with other congenital malformations. The theory of intra-uter- 
ine pressure and the persistence of a position of the scapula natural to 
a certain period of foetal life have been urged as the cause of some of 
the cases. 3 

In cases seen during childhood extensive division of the shortened 
muscles holding the scapula in its abnormal position is to be advised, 
and the removal of any bony bridge or projection. Marked improve- 
ment may thus be obtained. In older cases no operative treatment is 
advisable. 4 

1 Centralbl. f. Chir. , 1902. 

2 Wilson and Rugh : Annals of Surgery, April, 1900. 

3 Hibbs and Correll— Lowenstein : Zeitsch. f. Orth., xi., 1, p. 40. 
4 Freiberg : Annals of Surgery, May, 1889. 



CHAPTER XIII. 
TORTICOLLIS. 

Definition. — Etiology. — Pathological anatomy. — Symptoms. — Diagnosis. — Prog- 
nosis. — Treatment (Mechanical.— Operative). 

DEFINITION. 

The name torticollis is given to that distortion of the head which 
causes it to be held awry, and this condition is either constant or inter- 
mittent. 

The other names by which this affection is known are wry-neck, 
caput obstipum, collum clistortum, cou tortu, Schiefhals. 

ETIOLOGY. 

Torticollis may be congenial or acquired. 1 

i. Congenital Torticollis. 

(a) It may exist in connection with other deformities, such as club- 
foot and similar malformations. In these cases it seems proper to at- 
tribute its existence to those intra-uterine conditions causing other de- 
formities. 

(b) Abnormal pressure of the uterus seems to be accountable for 
another class of cases in which the cranium and face on the affected 
side are smaller at birth. 

(c) Amniotic adhesions are spoken of as a cause. 

(d) Inflammation of the muscles seems to be proved by the patho- 
logical findings in certain cases and must be mentioned as an occasional 
cause. 

(e) Arrest of the development of the muscles due to an affection of 
the nerves or nerve centres must be spoken of as a cause often ad- 
vanced to account for torticollis. 2 

(/) Rupture of the sterno-mastoid muscle occurring at birth has 

1 Trans. Am. Orth. Assn., iv., p. 293. — P. Redard : " Le Torticolis," etc., 
Paris, 1898 (full bibliography). 

2 Osier: N. Y. Med. Journ., December 12th, 1891. — Golding Bird: Guy's 
Hosp. Rep., 1890. — Shaffer: Trans. Am. Orth. Assn.. vol. iv.. p. 305. 

392 



TORTICOLLIS. 393 

been mentioned * as a cause of torticollis, and undoubted cases have 
been observed where torticollis has followed partial rupture of the 
sterno-mastoid at childbirth. Experiments, however, upon rabbits 
producing haematomata of the sterno-mastoid gave negative results. 
Furthermore, torticollis has not followed the haematomata from rupture 
of the sterno-mastoid at birth in a number of cases carefully watched 
by several observers. 

(V) Imperfections in the atlas and cervical vertebrae have in some 
reported cases been the cause of congenital torticollis. 

2. Acquired Torticollis. 

As the causes of the affection may be mentioned : 

(a) Cicatricial contraction of the skin or deeper tissues. 

(b) Traumatism to the neck and head. 

(c) Dislocation of the upper cervical vertebrae. 2 

{d) Inflammation of the muscle (rheumatic torticollis or acute or 
chronic myositis) . 

(e) Reflex irritation of the muscles in caries of the spine is well 
known, and in vertebral articular rheumatism this distortion may fol- 
low. Torticollis may also be seen in inflammation of the cervical lymph 
nodes or with deep cervical abscesses, retropharyngeal abscesses, in- 
flammations of the ear, parotitis, adenoid vegetations in the nasophar- 
ynx, tumors of the neck, and cerebral lesions. Neuralgia of the spinal 
accessory or cervico-brachial nerves may be accompanied by torticollis. 3 

(/) Difference in the plane or power 4 of vision of the eyes. 

(g) Lateral curvature. 

(fi) Voluntary habit 5 (physiological torticollis). 

(i) Occupations in which the overuse of one sterno-mastoid muscle 
is necessary, as in the case of a factory girl who was continually com- 

'Jeannel: " Encyc. Int. de Chir.," 1886, v., 777. — Busch : Berl. klin. Woch., 
1873, xxxvii. — Stromcyer: " Handb. der Chir. ," ii., 4. — Fischer: Deutsch. Chir., 
1880, Lief. 43. — Volkmann : Cent. f. Chir., 1885, xiv., 233. — Witzel : Deutsch. 
Zeit. f. Chir.. 1883, xviii., 534.— Petersen : Zeitsch. f. orth. Chir., i., L. 1, 113. — 
Fabry: Inaug. Diss., Bonn, 1885.— Cent. f. Chir., 1895, No. 1.— Deutsches Arch. 
f. Chir., 1882, p. 181; Cent, fur Gyn., 1886, No. 9.— Bouchut : " Traite Prat.de 
Mai. des Nouv. Nees," Paris, 1750.— Archiv f. Kinderheilkunde, 1891, Bd. xii., 5 
and 6.— N. Y. Med. Rec, February 27th, 1886.— Petersen : Cent. f. Gyn., 1896, 
No. 48. 

-Walton: Bost. Med. and Surg. Journ., cxlix., 17, 445. 

3 Dollinger: Pester med. chir. Presse, 1889, No. 48. 

4 Bradford: Trans. Am. Orth. Assn., 1889, vol. i., p. 46.— Lovett: Trans. 
Am. Orth. Assn., 1889, vol. i.— Gould: American Medicine, March 26th, 1904.— 
H. W. Kilburn : Boston Med. and Surg. Journ., March 24th, 1904. 

5 Mellet: "Manuel Prat. d 7 Orth.," Paris, 1844. 



394 ORTHOPEDIC SURGERY. 

pelled by her work to turn the head to one side, or in the case of a per- 
son carrying heavy loads continually on one shoulder. 

(j) Rickets. 

(k) Pott's disease of the cervical vertebrae. 

(/) Injury to the nerve centres at the time of birth. The affection 
may rarely involve both sides, as in a case figured by Whitman. 1 

(m) Paralysis of the spinal accessory nerve from such causes as 
rheumatism or trauma as well as anterior poliomyelitis 2 and the mus- 
cular dystrophies. 3 

Spasmodic Torticollis. — In this class are included those cases which 
arise from nerve irritation. This form may be central and occur in 
the distribution of the spinal accessory nerve, or it may be the local 
manifestation of a more general nervous irritation as in spinal irritation. 
In some cases of the spasmodic form, the affection is closely allied to 
writers' cramp, spasmodic tic of the face, etc., and in one case observed 
there was a nodding motion to the head. The spasm in this class of 
cases can be either tonic or clonic. 

Frequently no definite cause can be found to explain the occurrence 
of this form, but it is evidently the result of general malnutrition or 
general nervous disturbance having this as a local manifestation. Not 
infrequently in these cases there will be found a definite exciting cause, 
such as fright, grief, etc. In this class might be included the " torti- 
colis mental " of Brissaud 4 and Bompaire. 5 

Many of the above causes seem each to be but one out of many fac- 
tors. In a large percentage of cases there will be found to be a neu- 
rotic family or personal history ; also the general condition seems to 
have a very considerable influence. Many cases occur after severe 
overwork, in this particular bearing a close analogy to professional 
cramp or spasm. 

PATHOLOGY. 

The pathological condition existing in congenital torticollis has been 
demonstrated by autopsy and by pieces of muscle removed at operation. 
In some instances the contracted muscle appears normal, but more 
often the muscular substance is replaced by fibrous tissue. This may 
occur in small patches 6 or the whole muscle may be transformed into a 
tendinous band. In the majority of cases of fibrous degeneration of 
the muscle it is adherent to the sheath, and in some instances muscle 
and sheath are fused in one fibrous band. 

1 Bradford and Lovett : " Orth. Surg.," 2d ed., p. 632, Fig. 272. 

2 Hoffa: "Orth. Chir.," 4 th ed. 

3 Dejerine and Flandre, quoted by Redard : " Le Torticolis," 1898, p. 40. 

4 Union Medicale, 1894, p. 161. 

5 "Torticolis Mental," These de Paris, 1894. 

6 Volkmann: Cent. f. Chir , 1885, No. 14— Vallert: Ibid., 1890, No. 38. 



TORTICOLLIS. 395 

The sternal part of the muscle is more often involved than the cla- 
vicular. The changes described are to be classed as fibrous myositis, 
the reason for which has not yet been formulated. Other muscles 
besides the sterno-mastoid may be degenerated, and all of the struct- 
ures on that side of the neck are of course shortened. Changes to be 
classed as perimyositis have been demonstrated in certain cases. 1 
Shortening of the muscle on the affected side may amount to several 
centimetres. 2 

Secondary changes occur in long-continued torticollis. The most 
marked is asymmetry of the face ; a deviation of the line of the nose 
from a right angle to the line of the eyes is noticed ; furthermore, the 
distances from the outer point of the two eyes to the outer corners of 
the mouth are not the same, while the cheek on the contracted side is 
less prominent and the features on the affected side of the face are 
smaller than those upon the other side. This asymmetry diminishes if 
the deformity is corrected early. Asymmetry of the skull may also be 
found, as well as a diminished size of the cerebral hemisphere 3 on the 
affected side. The carotid artery of the affected side has been in 
certain cases found smaller. 4 

This asymmetry of the face may occur in acquired torticollis, and it 
may be present at birth in congenital cases. It may, on the other 
hand, be present at birth without the existence of torticollis. 

Lateral curvature of the spine will result from long-continued torti- 
collis, and a difference in the length of the clavicles has been noted. 

SYMPTOMS. 

Acute Torticollis. — In the acute form the history is that of an acute 
muscular rheumatism with some constitutional disturbance and sudden 
onset with a great deal of pain on movement of the head, and the head 
is held to one side. The acute stage, however, lasts but a short time 
and, in general, pain in wry-neck is not a permanent symptom. The 
chief discomfort from wry -neck is the disfigurement which is always 
noticeable and never to be concealed. The position assumed by the 
head is more or less typical and is described farther on. The chronic 
form may develop from the acute form. 

1 Archiv. d. Pediatric 1890. No. 1. 

2 Orth. Trans , iv., p. 305. 

3 Greffie: Montpellier Med , November 16th, 1890.— Broca : Bull. Med., 1894, 
No. 42, p. 493. 

4 Osier : N. Y. Med. Journ. , December 12th, 1891. — Golding Bird : Guy's Hosp. 
Rep., xlvii., 1890. — Krummacher : Cent. f. Chir. , 1889, No. xii. — Beely : Zeitsch. 
f. orth. Chir.,Bd. ii.— Meinhard Schmidt: Cent. f. Chir., July 26th, 1890. — Fal- 
kenburg: Deutsch. Zeit. f. Chir., 1885, xix., 338. — Bouvier: "Lee. Clin, sur les 
Mai.," etc., Paris, 1S58.— Stromeyer : " Handb. der Chir.," ii., p. 4, 1864. 



39^ 



ORTHOPEDIC SURGERY. 



Congenital Torticollis.— The position held by the head varies neces- 
sarily with the muscles affected. When the sterno-cleido-mastoid is 
attacked, the ear of the affected side is brought near to the sternum 
and the face slightly rotated to the opposite side. If the trapezius or 
posterior muscles are .also affected, the head will also be drawn back, 
the chin elevated above its normal level, and the features on the side of 
the spasm drawn below those on the opposite side. In addition to 
these muscles, the platysma, the scaleni, splenii, and other deep mus- 
cles of the neck are sometimes affected, and modify more or less the 
position of the head. The attitude is sometimes so peculiar as to ren- 
der it difficult to determine exactly what muscles are affected. On 
palpation certain muscles will be found to be hard to the touch and 
others flaccid. Rotation of the head is free up to a certain limit, vary- 
ing in extent. It is not possible to move the head in a direction against 
the contraction or spasm, and a persistent effort may cause considerable 
pain. 

Spasmodic Torticollis. — The intermittent form of torticollis is not 
infrequent. It is due to imperfect muscular balance from overstrain of 
certain groups of muscles which are affected by spasmodic attacks. 
This condition is not unlike that noted in writers' cramp and similar 





FIG. 359.— Ocular Torticollis. Habitual 
position of head. 



Fig. 360. — Ocular Torticollis; Back 
View. Habitual position. 



muscular disturbances seen in occupation neuroses. At times the head 
can be held in a proper position, but locomotion or any excitement or 
the apprehension of being observed may produce such a contraction 
of the head that it will be twisted violently to one side and rotated to 
an extreme limit. A slight pressure of the hand steadying the head 



TORTICOLLIS. 



397 



will ordinarily correct it, but when the muscular contraction becomes 
excited, great force is required to hold the head in place. In some cases 
the contraction may be slow and steadily increase to its maximum. In 
a recumbent position the contraction does not ordinarily take place. 
It usually disappears during sleep. The spasm is sometimes tonic and 




FIG. 361. — Torticollis Showing Contraction 
of the Right Sterno-mastoid. 



FIG. ^6: 



-Torticollis due to Cervical Pott's 
Disease. 



sometimes clonic, and sometimes pain is excited by the muscular con- 
traction. It is usually confined to the muscles of one side (tic gira- 
toire). It may be accompanied by severe attacks of pain, and may in- 
volve the muscles of the back. Slight twitchings of the muscles are 
sometimes observed for some time previous to an outbreak of the spas- 
modic condition. 

DIAGNOSIS. 

There is no difficulty in recognizing the deformity called wry -neck. 
The head is twisted to one side, the chin being to the right or left of 
the sterno-clavicular notch, while the face is turned to one side and 
partly upward. The shoulders are held obliquely to the trunk, twisted, 
in order to bring the face so far as possible in a vertical line. Certain 
of the muscles, frequently the sterno-cleido-mastoid, are felt hard on 
palpation; some rotation of the head is possible, but perfectly free 
rotation of the head is checked by the contracted muscles. 

A diagnosis of the cause and situation of wry-neck is more difficult, 



39 8 ORTHOPEDIC SURGERY. 

as well as an attempt to distinguish it from other affections which give 
rise to this malformation, a matter which is of great importance. Such 
are disease of the cervical vertebra, enlarged cervical glands, cervical 
abscess, and stiff neck from ordinary cold. 

The diagnosis between anterior and posterior torticollis (or torti- 
collis due to contraction of the anterior muscles, chiefly the sterno- 
cleido-mastoid, and that due to the contraction of the posterior muscles, 
the trapezius and splenius capitis, etc.) is to be based on palpation 
chiefly. 

Palpation also, with a clinical history of paralysis and the evidence 
of paralysis elsewhere, is sufficient usually to determine the diagnosis 
of paralytic torticollis. 

Torticollis dependent upon enlarged and inflamed glands can usually 
be recognized by the evidence of glandular enlargement. 

There is ordinarily little difficulty in recognizing the common acute 
wry-neck. Its course is acute, the deformity appears suddenly, and it 
is usually accompanied by pain. Improvement is to be noticed in a 
comparatively short time. 

For the diagnosis of congenital torticollis from that due to Pott's 
disease the reader is referred to the chapter on Pott's disease, but it 
may be said that in the latter there is greater rigidity, and this involves 
all the muscles of the neck, and particularly the posterior groups. The 
pain elicited by attempts to twist the head is greater. When a patient 
with cervical caries attempts to lie down or turn over the head is in- 
stinctively steadied with the hand, while in true torticollis this is not 
so constant a symptom. 

Cases of posterior torticollis, i.e., that form described by Delore, 
involving the posterior muscles of the neck, resulting from vertebral 
rheumatism, is rare. It can be recognized by the absence of contrac- 
tion of the sterno-mastoid and the history of the case. 



PROGNOSIS. 

The acute idiopathic wry-neck due to muscular inflammation runs a 
short course and tends naturally to recovery, though in a few cases it 
may become chronic. Torticollis due to abscess of the cervical glands 
terminates with the complete discharge of the abscess as a rule. Inter- 
mittent spasmodic torticollis may become cured spontaneously, or may, 
as is more common, remain without change for many years. Congeni- 
tal forms of torticollis and the common acquired form (associated with 
muscular contraction which has become chronic and developed fibrous 
muscular degeneration) demand surgical intervention. No constitu- 
tional disturbance follows this affection, which is more distressing on 
account of the unsightliness than from any actual discomfort. 



TORTICOLLIS. 



399 



The deformity is one which is eminently curable by surgical inter- 
vention. Complete correction and permanent cure are possible in all 
cases except in the intermittent form, which is dependent upon a gen- 
eral depressed state of the nervous system, in which a cure cannot 
always be promised. 

TREATMENT. 

In acute torticollis due to the inflammation of the muscles, the 
treatment is largely the alleviation of the symptoms. This is best done 
by the application of moist heat. Rest of the head and antifebrile con- 
stitutional treatment are of course advisable when there is any fever. 

Torticollis due to cervical Pott's disease is treated according to the 
principles of treatment of that affec- 
tion, and will disappear with the im- 
provement of the bone disease. Tor- 
ticollis due to muscular contraction 




Fig. 363. — Torticollis Brace, Front View. 



Fig. 364. — Torticollis Brace Applied, 
Back View. 



secondary to cervical abscesses or enlarged glands is corrected by 
the proper treatment of cervical abscess. Torticollis due to an affec- 
tion of the eye is to be corrected by proper ocular treatment. 

Congenital Torticollis. — The treatment of wry -neck due to perma- 
nent muscular contraction is either operative, or purely mechanical, or 
mechanical and operative. 

Mechanical Treatment. — Mechanical treatment without the aid 
of operation is usually unsuccessful or but partially successful, except in 
the lightest cases. 



400 ORTHOPEDIC SURGERY. 

Massage and passive manipulation are of value in mild cases in con- 
nection with mechanical treatment. 

A simple form of appliance is that introduced by Buckminster 
Brown, of Boston (Chapter XXI., 24). A stiff wire collar passes 
around the neck, furnished with a plate under the chin, arranged so as 
to press on the deflected side of the chin. Pressure is also arranged to 
be applied to the inclined side of the head behind the ear. The wire 
collar is attached to a ring which rests upon the shoulder, and is fur- 
nished with arms which pass down the back. 

Mechanical treatment is to be regarded as of value chiefly in retain- 
ing the correction obtained by operative measures. 

Operative Treatment. — -Before the introduction of aseptic sur- 
gery the dread of deep suppuration of the cervical fascia certain to fol- 
low deep dissection favored the employment of subcutaneous tenotomy 
of the sterno-cleido-mastoid tendon, followed by mechanical stretching. 
Failure or imperfect results followed these imperfect methods. Sub- 
cutaneous tenotomy is to be rejected as dangerous if freely employed 
and lacking precision. Open incision of the contracted muscular tissues 
can be both precise and thorough, and the results are entirely satisfac- 
tory. 

In the usual form of torticollis the contracted muscle, the sterno- 
mastoid, is easily attached. Division is made (i) either at the sternal 
and clavicular insertion, or (2) at its origin at the mastoid process. 

Division at the Stemo-Cleido Insertion. — An incision of the skin is 
made parallel to the clavicle, laying bare the insertion of the muscle. 
The incision should be sufficiently long to expose the whole attachment, 
as it is desirable that no undivided fibres remain. It is desirable that 
the resulting scar, if any, should be concealed below the clothing and 
not appear in the neck. This can be accomplished by dividing the skin 
while the head is bent forward, cutting down upon the clavicle and 
drawing the elastic skin slightly upward from the chest. If, after the 
division, the head is strongly retracted, as is desirable to give the mus- 
cular attachments necessary prominence, the incised skin will gape suffi- 
ciently above the clavicle to give room for division of the muscle, aided 
if necessary by hook retraction of the skin. The tissues to be divided 
are to be carefully freed from all overlying tissue and a director passed 
under the sternal tendon, care being taken that the director is passed 
completely under and not through the muscular attachment. 

It is usually necessary that both the clavicular and sternal attach- 
ments of the muscle be divided to prevent any possibility of relapse, 
and for this reason the skin incision should be made sufficiently long to 
give ample room. With ordinary care there is no danger of dividing 
the vessels, although they are in close proximity. 

The external jugular is so superficial that it can always be seen. It 



TORTICOLLIS. 



401 




usually lies farther to the outside than the line of incision. The inter- 
nal jugular and the artery are separated from the field of operation by 
the deep fascia, and, if the sterno-cleido muscle is made prominent and 
stretched by placing the head backward, the muscular insertions can be 
completely divided without great risk. 

In open incision there is danger of wounding the internal jugular 
vein; deaths from this cause have been reported after tenotomy. The 
writers would record one case in their experience in which the internal 
jugular was wounded in an open incision. It was tied and no untoward 
results followed, the patient making a perfect recovery. The vein lies 
under the deep fascia, and can be 
avoided in open incision if the 
neck be not stretched and care be 
taken not to open the deep cervi- 
cal fascia. 

Mastoid Division of the Sterno- 
Cleido-Mastoid Muscle. — A divis- 
ion of the sterno-mastoid at its 
origin from the mastoid process 
has been advocated on the ground 
that the incision is away from the 
vessels and that the resulting scar 
is in a less noticeable region. For 
this division an oblique skin incis- 
ion is made along the sterno- 
mastoid, beginning behind the ear 
and extending nearly to the middle 
of the muscle. The muscular or- 
igin is much thicker than the 
clavicular insertions and care will 
be needed to divide the muscle 
thoroughly. The muscle is also 
divided through an oblique incis- 
ion along the lower third of the muscle. The incision should be a 
free one if the division is complete. The muscle is thick in this region, 
but, being prominent and superficial, is easily separated from other 
tissues. 

The choice as to incision will rest with the judgment of the surgeon. 
The division of the sternal and clavicular attachment appears to 
have certain advantages, in that the muscle is more nearly tendinous 
than in the other portions and can therefore be divided more satis- 
factorily. 

Whatever incision is employed, especial care should be taken to 
promote the healing of the skin. A buried skin suture should be em- 
26 




Fig. 365.— Result of Open Incision One Year 
after Operation in a Girl of Sixteen. Shows 
also the unequal development of the face. 



402 



ORTHOPEDIC SURGERY. 



ployed, and the wound protected by silver foil from the irritation of the 
dressing. 

The neck and chest are covered with sheet wadding and the head is 
fixed in an overcorrected position by plaster bandages applied around 
the head, shoulders, and thorax. A window can be cut over the incis- 
ion for the examination of the wound, but under proper precautions the 
wound can be expected to heal rapidly and to need no further dressing. 
It is unnecessary for the patient to remain in bed longer than a few 
days, if satisfactory plaster fixation is furnished. Under some circum- 





FlG. 366.— Posterior Torticollis Before Forc- 
ible Straightening. 



Fig. 367.— After Operation. 



stances, however, it is desirable to avoid a cumbersome plaster helmet, 
and recumbency for two weeks is preferred. It is necessary that thor- 
ough overcorrection should be furnished during the period of healing. 
This can be accomplished by securing the patient on a gas-pipe frame, 
with the shoulders firmly fastened. Three strips of adhesive plaster 
with a long strip of webbing sewed to one end of each are applied to the 
patient's head — one across the forehead, with the tape arranged to pass 
under the head; a second on the side operated upon, with the tape 
passing over the head ; the third on the opposite side, with the tape 
passing under the chin. If light weights are attached to the ends of 
the tapes and pass over sand bags placed at the sides of the face, a cor- 
recting pulling force can be exerted in three directions — one pulling the 
chin to the side not operated upon, the second inclining the long axis 
of the head in a direction the reverse of its former inclination, and the 
third rotating: the face toward the unaffected side. This method of fix- 



TORTICOLLIS. 403 

ation will be found of use where it is difficult to secure the adequate 
amount of overcorrection of the deformity at the time of operation. It 
should be borne in mind that not only correction but overcorrection, at 
or immediately after the operation, is necessary to prevent a relapse, 
which will follow to a greater or less degree if contracted tissues 
remain. 

After the wound is entirely healed the patient should wear, for from 
three to six months, a retaining appliance holding the head in an over- 
corrected position. This can be a plaster bandage, a leather moulded 
on a plaster form, or a steel appliance (Chapter XXI., 24). 

Massage will aid in the recovery of muscular tone. 

The results of the correction of torticollis by open division are 
extremely satisfactory. The asymmetry of the face becomes more 
noticeable after correction than it was in the deformed position, but in 
children disappears gradually if the corrected position is retained. 
Resection of the lower two-thirds of the sterno-mastoid muscle has been 
advocated, on the ground that after-treatment is shortened and relapse 
prevented. It seems unnecessary, however, as it leaves a long scar, and 
as simple division and proper after-treatment are efficient in correcting 
the deformity. 1 

Posterior Torticollis. — Besides the deformity largely associated with 
contraction of the sterno-mastoid muscle — anterior torticollis — another 
form is seen, as has been already mentioned, viz., posterior torticollis. 
This variety constitutes a class of obstinate cases. The only efficacious 
treatment is that of forcible correction without tenotomy, for the reason 
that, as a rule, the muscles are too deep or extensive to be tenotomized. 
The writers have divided the outer bands of the anterior scalenus and 
trapezius by open incision and can report the feasibility of the proced- 
ure. In correcting this deformity the patient should be thoroughly 
anaesthetized, and an assistant should hold the shoulders firmly, while 
the patient should be so placed that the head projects beyond the end 
of the operating-table. The head should be held by the hands of the 
surgeon and rotated in all directions, considerable force being used. 
The danger of fracturing the spine is in such cases, of course, so slight 
as to be disregarded, and the deformity can be overcorrected. After 
the operation the head should be fixed, the after-treatment resembling 
that of the ordinary torticollis. 

Spasmodic Torticollis.— Great difficulty is met in the treatment of 
spasmodic torticollis as compared to the congenital torticollis, from the 
fact that the constitutional nature of the affection (due to impaired 
nervous condition) is an important factor to be considered. The affec- 
tion may be considered a localized chorea or a disturbance of the proper 
muscular balance of the muscles holding the head. Of the constitu- 
'Zeitsch. f. orth. Chir., xi., 3, 417. 



404 ORTHOPEDIC SURGERY. 

tional treatment nothing need be said, further than that the success of 
treatment will depend upon the removal of the patient from all depress- 
ing influences, one of which is the distress caused by the unequal musl 
cular action sometimes accompanied by severe pain. The surgical 
treatment consists of measures of fixation, muscular rest, muscular 
development, and operative measures. In many instances the irregular 
action of certain muscles is due to their fatigue from overstrain. The 
affection may be considered a muscle revolt. 

Treatment by Rest and Fixation. — Treatment by absolute rest 
of all muscles sustaining the weight of the head is indicated. This 
can be furnished by placing the patient in a recumbent position without 
pillows and fixing the head by sand bags applied at each side of the 
head. A plaster bandage can be applied or a moulded leather substi- 
tute holding the head, shoulders, and trunk firmly, relieving the mus- 
cles from any weight-bearing strain. 1 With this the patient is relieved 
of the restraint of recumbency. Local applications can be made to the 
muscles with electricity and massage. 

Treatment by Muscular Training. — Great benefit may follow 
carefully directed and graded exercises. 

Treatment by Operative Measures. — The tedious nature of con- 
servative treatment suggests the employment of operative measures. 
The restoration of muscular balance by myotomy, fasciotomy, and the 
incident temporary muscular rest is observed in the surgical treatment 
of muscular spasm in spastic paralysis, and the same principles can be 
applied in spasmodic torticollis. The muscles involved are not only the 
sterno-cleido-mastoid, but the various muscles in the back of the neck. 
Stretching, division, and excision of portions of the nerves supplying 
these muscles have been employed. Of these procedures the latter 
(viz., extirpation of the nerves) has been followed with the best result. 
As this involves a somewhat free dissection of the tissues, it has been 
suggested that the benefit following the procedure is due more to the 
dissection and freeing of the contracted tissue than to the paralysis. 
Kocher advises myotomy and fasciotomy alone rather than nerve resec- 
tion. Richardson and Walton, however, report good results following 
the latter procedure. 

The nerves to be divided are the spinal accessory from the sterno- 
mastoid, and a secondary operation on the nerve roots of the deep pos- 
terior cervical plexus. 

Spina/ Accessory Nerve. — This nerve is divided and excised for 
spasmodic wry-neck. It may be reached anterior to the sterno-cleido- 
mastoid, an incision being made along the anterior body of the muscle, 
passing two inches downward from the lobe of the ear. The muscle is 

1 H. J. Hall: Orth. Trans., vol. xi.. p. 233. — Boston Med. and Surg. Journ., 
March 9th, 1899, p. 236 



TORTICOLLIS. 405 

turned to the outside and the nerve can be found a little above the level 
of the hyoid bone. If it be desirable to reach the nerve, as is possi- 
ble, from the sterno-cleido-mastoid, the incision is made along the outer 
border of the muscle, the centre of the incision being the centre of the 
muscle. The nerve will be found a little above this point. 

Division of the Nerves in the Deep Posterior Ceivical Plexus. — Keen 
divides the posterior branches of the first, second, and third cervical 
nerves in spasmodic torticollis, which has been unrelieved by the in- 
cision of the spinal accessory. A transverse incision is made half an 
inch below the level of the lobule of the ear. The trapezius muscle is 
divided in the same line. The muscle is then dissected up and the 
great occipital nerve is found. The complexus is then divided, and the 
great occipital nerve is f ollowed until its origin from the posterior division 
is reached. The suboccipital or first cervical nerve is excised. It lies in 
the triangle close to the occiput formed by the two oblique muscles and 
the posterior straight muscle. The exterior branch of the posterior 
division of the cervical nerve is found lower down, and should be divided 
close to the bifurcation of the main nerve. 

The anterior branches of the cervical plexus may be reached by 
means of an incision along the posterior border of the sterno-cleido- 
mastoid muscle. 

Even after operative intervention careful after-treatment by muscle 
training is necessary to obtain permanent cure. 

In the absence of complete statistics it is impossible to state the 
absolute relative value of the different methods of treatment. The 
treatment in obstinate cases needs to be thorough. On the failure of 
non-operative treatment, thoroughly and persistently applied, operative 
measures are to be employed. Reasoning from analogy, sections of 
contracted muscular tissue are as valuable as nerve excision. 



CHAPTER XIV. 
ANTERIOR POLIOMYELITIS. 

Definition. — Etiology. — Pathology.— Symptoms. — Diagnosis. — Differential diag- 
nosis. — Prognosis. — Treatment. 

Anterior poliomyelitis or infantile spinal paralysis is an affection 
which attacks chiefly children. It comes on with a sudden onset and 
deprives certain muscles and often an entire limb of muscular power, 
and the parts affected undergo rapid atrophy. The paralysis is a purely 
motor one. 

The pathological name of the affection is acute anterior poliomye- 
litis, and other common names are: Infantile paralysis, essential paral- 
ysis of children, acute atrophic spinal paralysis, " teething palsy " or 
dental paralysis. Regressive paralysis (Barlow), myelitis of the anterior 
horns (Seguin), myogenic paralysis (Bouchut). German: Kinderlah- 
mung, spinale Kinderlahmung, essentielle Kinderlahmung. French: 
Paralysie spinale, paralysie infantile, paralysie des petits enfants, para- 
lysie essentielle de l'enfance, tephromyelite anterieure aigue (Charcot), 
etc. 

The disease was first mentioned by Underwood i in 1784, but it was 
not then separated clearly from the other kinds of paralysis affecting 
children, and it remained for Heine to give the first accurate account 
of the disease in 1840. 

ETIOLOGY. 

Little is known of the causation of infantile paralysis. 2 The disease 
is usually limited to the time of the first dentition in children. In 
12,694 cases of orthopedic affections in children under twelve seen at 
the Children's Hospital, Boston, there were 987 cases of anterior polio- 
myelitis. In 599 cases (Seeligmuller, Galbraith, Sinkler, Gowers, and 
Starr) 472 occurred before the fourth year, 118 in the first, 214 in the 
second, 140 in the third, and 52 in the fourth. It has been reported 
as occurring in a baby four weeks old. 3 The disease has been seen as 

'"Treatise on the Diseases of Children," London, 7th ed.. 1S26, p. 251. 

2 Duchenne fils : Arch. gen. de Med., tome ii., 1864. — Seeligmuller : Gerhardt's 
" Handbuch der Kinderkrankheiten," v., 1S81, p. 1. — Wharton Sinkler: Keating's 
" Encyclopedia," p. 683. 

3 Schultze : " Lehrb. der Nervenkrankheiten," Stuttgart, 1898, p. 223. 

406 



ANTERIOR POLIOMYELITIS. 407 

early in life as the twelfth day in a case of Duchenne's, and adults are 
not exempt from a similar affection. 

Exposure to severe heat and sunstroke are mentioned as occasional 
causes of the attack of paralysis. Most cases occur during warm 
weather. Twenty-seven of Barlow's 53 cases occurred during July and 
August, and Sinkler found that in 213 out of 270 cases the disease oc- 
curred from May to September inclusive. 

An acute feverish attack, like indigestion, is often assigned as the 
cause, but inasmuch as it may be the chief symptom of the onset, no 
weight can be attached to it. 

Certain other cases seem to come on after a fall, and it is quite pos- 
sible that a traumatic hemorrhage into the substance of the cord might 
occur, causing much the same symptoms as anterior poliomyelitis, but 
such traumatic histories are rare. 

As a matter of fact, the disease attacks healthy and unhealthy chil- 
dren, boys and girls alike, usually without any demonstrable cause, com- 
ing on in the midst of perfect bodily health, and apparently the affection 
has no dependence upon a hereditary influence. It is by far the com- 
monest paralysis in children and in most cases develops during the night 
rather than the day and commonly during the hot months. 

Modern opinion rather inclines toward regarding the affection as 
infectious in origin, although the infecting organism has not been defi- 
nitely demonstrated. Fresh cases have been investigated as to the 
presence of a micro-organism, with negative results for the most part. 
Schultze, 1 however, in a case of what he considered anterior poliomye- 
litis of the arms and neck in a boy of five, did a lumbar puncture on 
the thirteenth day, and found in the cerebrospinal fluid withdrawn an 
organism which he described as the Weichselbaum-Jager diplococ- 
cus. The later history of the case was that of infantile paralysis. 
As a somewhat similar form of paralysis follows certain cases of 
cerebrospinal meningitis, this evidence cannot be accepted as con- 
clusive. 

The affection occurs at times as an epidemic, which lends force to 
the view of its infectious character. Such epidemics have been 
reported from time to time. 2 The earliest was in 1843. 3 Medin 4 re- 
ported 44 cases occurring in Stockholm in the summer of 1887. There 
were three deaths, and although in general the ordinary type of infan- 
tile paralysis was followed, a few aberrant cases were seen. Briegleb 5 
reported an epidemic in 1890. 

1 Munch, med. Wochenschr. , 1898, No. 38, p. 1197. 

-Painter: Orth. Trans., vol. xv., p. 414. 

3 Colmer: Am. Jour. Med. Sciences, 1843. 

4 Medin: Proceedings Tenth Int. Cong., vol. ii., div. iv. 

5 Briegleb: Inaug. Diss., Jena, 1890. 



408 ORTHOPEDIC SURGERY. 

The epidemic reported by Caverly J in Vermont, around Rutland, in 
the summer of 1894, was very extensive and very severe. The epi- 
demic included 132 cases, and 18 cases were fatal. The cerebral tracts 
were in several cases involved. An epidemic in Australia was reported 
by Alston in 1897, consisting of 14 cases. 2 An epidemic in Cherry- 
field, Me., was reported by Madison Taylor. There were 7 cases with 
1 fatality. 3 W. Pasteur 4 reported in 1896 an epidemic occurring in 7 
members of the same family. A very careful investigation of an epi- 
demic occurring in North Adams, Mass., was made by Brackett. 5 Ten 
cases were seen and examined which in general were of a more severe 
type than ordinary cases. The initial fever was high, the distribution 
of paralysis was on the whole more extensive. The sphincters were at 
times involved, and prolonged hyperesthesia was found in the severer 
cases. These features seem in general to characterize the epidemic 
cases as described by others. At North Adams all of the cases but one 
occurred along the banks of the two rivers flowing through the town ; 
no other common etiological factor could be found. 

PATHOLOGY. 

The study of autopsies 6 in recent cases of infantile paralysis has 
resulted in the opinion among recent writers that the entire gray mat- 
ter of the cord is the seat of interstitial inflammation and that the 
changes in the ganglion cells are secondary 7 (Sachs). Goldscheider's 
study would make it appear that the blood-vessels are first affected and 
that from these the neuroglia is attacked, and that the changes in the 
ganglion cells are degenerative and secondary in them as well as in the 
nerve fibres. The cases of Siemerling are confirmatory, and both sets 
lead to the view that the inflammation is interstitial and not parenchy- 
matous. 

The process may involve a few segments of the cord, or it may in- 
volve a greater part of the cord and extend to the medulla and pons. 
The larger ganglion cells of the anterior horns in the affected area dis- 
appear and the ones that remain are shrunken and the cell processes 
have disappeared. The entire gray matter of the affected side shrinks 
and even the white matter is smaller than that of the other side. The 

1 Journ. Am. Med. Assn., January 4th, 1896. 
•Australian Med. Gaz., April 24th, 1897. 

3 Boston Med. and Surg. Journ., cxxix. , 504. 

4 Trans. Clin. Soc. of London, 1896, p. 143. 
6 Trans. Am. Orth. Assn., vol. xi., p. 132. 

6 Goldscheider : Zeit. f. klin. Med., xxiii., 1893, p. 494. — Dauber: Zeit. f. Ner- 
venheilkunde, vol. iv.— Siemerling : Arch. f. Psychiatric xxvi., 267(with literature 
to 1894). 

7 Von Kahlden : Cent. f. Path., September 14th, 1894 (Charcot's view). 



ANTERIOR POLIOMYELITIS. 409 

columns of Clarke disappear and the anterior nerve roots become 
smaller than those of the other side. 

Atrophic changes soon take place in the paralyzed limb. Some- 
times the atrophy affects the bones, which become shortened even to 
the extent of affecting the length of a limb by several inches. At the 
same time the affected limb grows comparatively smaller in circumfer- 
ence than that of the opposite side. This is frequently the result of 




FIG. 368. — Anterior Poliomyelitis. Chronic stage; section through sixth cervical segment; 
diminution of anterior gray matter and of entire half of right side. (Sachs.) 

retarded growth rather than of real wasting, but both factors at times 
enter into the change. In other instances, even in severe cases, the 
bones seem but little affected, while the atrophy of the muscles is very 
marked . 

The epiphyses are stunted, and the ligaments become thin and 
loose, and dislocations and distortions of the joints are favored. It is 
in the muscles that the most notable changes are found. These waste 
rapidly and become flabby to the touch, and microscopic examination 
shows a loss of striation followed by a granular degeneration of the 
fibres until little is left beyond muscle corpuscles and fat granules con- 
tained in sarcolemma. This, of course, is clearly more than the atro- 
phy of disuse. 1 

That poliomyelitis represents an acute inflammatory condition of the 
anterior gray matter of the spinal cord is conceded on all sides, but the 
question arises what the origin of such inflammation may be. The 
only satisfactory explanation at the present day is to suppose that the 
inflammation is the result of an acute infection which happens to be 
located in the spinal cord, just as other infectious diseases show a 
predilection for other sites in the body. The microbic origin has not 
yet been satisfactorily demonstrated, but all the clinical facts point 
toward this view, and the close dependence of the myelitic process upon 
the distribution of the blood-vessels lends further color to this theory. 2 

1 Gowers : "Dis. of Nervous System," vol. i., 253. — Jacob v. Heine : Loc. cit. 
-Sachs: "The Nervous Diseases of Children," New York, 1895. 



410 ORTHOPEDIC SURGERY. 

SYMPTOMS. 

In general the clinical history of the disease falls into three stages : 

(a) The onset, to which stage belong the acute febrile symptoms 
and the development of paralysis. 

(b) The stage of convalescence, which begins at the time of the full 
development of the paralysis, and is followed by a brief stationary 
period, and finally rapid and then slower improvement until a stationary 
period is reached. 

(c) The stage of deformity, in which wasting of the affected limb is 
present and static, paralytic, and contraction deformities have super- 
vened. 

No arbitrary subdivision of the classes of symptoms will be made, 
because in reality the stages run into each other so gradually that it 
seems unjustifiable to divide them practically. 

Infantile paralysis is oftenest ushered in by a mild or severe febrile 
attack, which presents no definite characteristics to distinguish it from 
any ordinary attack of cold or indigestion. The elevation of tempera- 
ture is not excessive, commonly from ioo° to 102 F., sometimes even 
104 . With this fever are apt to be associated vomiting, convulsions, 
giddiness, or other cerebral disturbance, sometimes even delirium. 
Older children complain of pain in the back and limbs. There is, as a 
rule, no warning of the attack, although Seeligmiiller has noted at 
times a disinclination to walk or stand as much as usual for some days 
preceding — a fact quite in accordance with Lange's theory that over- 
exertion of the muscles has much to do with the production of the dis- 
ease. Convulsions may be present, and when they occur they are 
usually followed by a period of unconsciousness. The feverish attack 
at the onset may, however, be very severe, at times lasting two or three 
days (or even weeks) before the paralysis appears. More commonly, 
however, it is very slight and scarcely noticed. In certain rare cases, 
two or even three attacks of fever are noted, each followed by an in- 
crease in the paralysis. Pain of a rheumatic character in the back and 
limbs is a common initial symptom. In certain cases all feverish and 
other symptoms are absent at the onset, and the child is suddenly dis- 
covered to be paralyzed in one or more limbs. Such paralysis comes on 
oftenest in the night, but it has been observed to come on quietly in 
the daytime, while the child was at play. In these cases there may be 
no succeeding illness, and the paralysis is the only symptom through- 
out. 

Diarrhoea, vomiting, general hyperesthesia, and much nervous irri- 
tability are other symptoms which often accompany the onset of the 
paralysis. During the first few days there may be paralysis of the blad- 
der with retention or incontinence of urine, but it disappears after a 



ANTERIOR POLIOMYELITIS. 41 l 

few days or weeks. Pain is a symptom but little noted in infantile 
paralysis, but it is not uncommon, nor does it indicate of itself the 
presence of any additional pathological process. 

The paralysis itself very quickly becomes manifest and reaches its 
maximum within a few hours of the attack, or within a day or two, 
except in rare cases. Having reached its maximum and remained sta- 
tionary for a short time, improvement almost invariably begins. In 
rare cases improvement begins immediately after the attack and pro- 
ceeds to complete recovery. These are the cases which are spoken of 
as " temporary spinal paralysis." The more common course is for the 
paralysis to remain nearly stationary for a time varying from two to six 
weeks, and then to improve, at first rapidly and then more slowly, for 
three or four months. After six months have passed, further sponta- 
neous improvement is unusual. 

Vascular changes become very marked. The temperature of the 
limb is much lower than that of the other. The limb is generally blu- 
ish, with a superficial stagnation of the blood, on account of an atrophy 
of the blood-vessels and consequent diminution of their calibre, and 
when the blood is pressed out of the surface capillaries by the finger it 
returns slowly. On account of this vascular sluggishness ulcers may 
form, which are slow to heal and very painful. The limb even very 
early loses its normal appearance, and the flaccid undeveloped look of 
the foot or hand is most noticeable. 

Atrophy of the affected muscles begins to be perceptible a few 
weeks after the onset of the paralysis, while the loss of striation in the 
muscular fibres can be detected with the microscope within two or 
three days of the attack. 1 The muscles may be tender to the touch 
during the time that they are wasting so fast, especially in adults 
and older children. Muscles seriously affected are toneless and 
flaccid from the first, and in the late stages of wasting scarcely any 
volume of muscles seems left when the limb is grasped with the 
hand. 

The paralysis is a purely motor one, and although tingling and for- 
mication may be present, sensation is very rarely affected. The reflexes 
are abolished in the affected limb if the implication of the extensor 
muscles of the thigh be enough to do away with the knee jerk of the 
affected side. 

Sometimes after an attack the paralysis may seem to be general, 
but the probabilities are that after improving in general, the loss of 
power will eventually be localized in one limb, and that if one limb orig- 
inally is paralyzed the likelihood is very great that a certain amount of 
power will be regained, leaving only certain groups of muscles perma- 
nently paralyzed. 

1 H. W. Berg : Wood's " Ref. Handbook," vcl. v., p. 504, 



412 



ORTHOPEDIC SURGERY. 



Distribution. — The paralysis in its distribution is monoplegic in 
about half the cases, as the tables taken from the cases of Duchenne, 
Seeligm tiller, Sinkler, and Starr will show: 



Both legs, ... 








170 


One leg, ..... 








246 


Both arms, .... 








6 


One arm, . . 








47 


All extremities. 








47 


Arm and leg, same side, . 








33 


opposite sides, . 








8 


Trunk, 








26 


Three extremities, . 








12 



595 



The great preponderance of paralysis of the lower extremities is to 
be noted, and the liability to paralysis increases even from the thigh to 
the foot, and when improvement begins in a case in which both an 
upper and a lower extremity are paralyzed, the improvement begins first 
in the arm. Commonly certain groups of muscles are attacked, and 
when adjacent muscles are affected they seem to be selected at random 
oftener than by functional or anatomical association. In the leg, the 
extensors and the peronei are the muscles oftenest affected. The glu- 
tei are never affected alone, but they commonly share in any extensive 
paralysis of the leg. In the arm the deltoid suffers oftener than any 
other arm muscle, either alone or in association with other muscles. 
The " upper-arm type " of paralysis, which Erb has described, consists 
of the simultaneous affection of the deltoid, supra- and infraspinatus, 
the biceps, and the supinators. There is also a "forearm type" de- 
scribed by Remak, 1 in which, as in lead paralysis, the extensor muscles 
of the hand are paralyzed while the supinator longus is spared. The 
serratus magnus is sometimes affected as well as the trapezius and pec- 
toralis major. The neck muscles are very seldom affected and the mus- 
cles supplied by the cranial nerves only rarely. 

The muscles of the back may be paralyzed and the patient be una- 
ble to sit erect, or lateral curvature may result- — a state of affairs often 
made worse by allowing the patient to sit erect while the muscles are 
still weak. The diaphragm is occasionally paralyzed. In those rare 
cases of paralysis of the abdominal muscles, the patient leans back to a 
very marked degree, missing the restraining action of the abdominal 
muscles. There are, finally, cases of universal paralysis in which death 
soon takes place from interference with respiration. 

The sequelae of the disease are few. 

] Remak : Arch. f. Psych., Band ix., 1878-79, p. 510. 



ANTERIOR POLIOMYELITIS, 4 J 3 

Deformities. — The deformities which come on after infantile paraly- 
sis are late events in the history of the disease and rarely develop until 
at least some months after the attack. They are, as a rule, progressive 
in their character and the end results are often such extreme distor- 
tions that the affected limb is useless. The deformities fall into two 
chief classes: (i) deformities due to trophic changes, such as bone 
shortening, etc. ; (2) deformities due to muscular paralysis. 

(1) The first class is comparatively unimportant; shortening of the 
paralyzed arm or leg may take place with atrophy of the bone in every 
direction, so that a liability to fracture is of course a necessary conse- 
quence. Shortening of the arm is comparatively unimportant in itself, 
but shortening of the leg is likely to induce lateral curvature of the 
spine from the necessarily tilted position of the pelvis * due to the urn 
equal length of the legs. 

(2) The deformities of the second class, which are the result of 
muscular paralysis, are manifold and form the great bulk of the cases 
of deformity in anterior poliomyelitis. As a rule they do not appear 
earlier than two or three months after the onset and more commonly 
not for many months. 

For clinical consideration they fall into two groups: deformities 
caused by contraction, and deformities due to laxity of the muscles and 
ligaments. Volkmann, on the ground of H liter's investigations, ex- 
plained nearly all the deformities on mechanical grounds, urging that 
the deformities were developed partly by reason of the w r eight of the 
limbs concerned and the position which they assumed when at rest, and 
partly because of the muscular insufficiency of the affected limbs which 
allowed the articular surfaces to be subjected to an excessive pressure 
when brought into use, which had the effect of gradually pressing them 
into abnormal position. The earlier idea had been, however, that they 
were brought about by the unopposed action of the muscles which were 
not affected. Probably both factors are active in the causation of de- 
formity. 

A word should be said in regard to the reason of the more severe 
affection of the anterior leg and thigh muscles than of the posterior 
muscles in nearly all cases. The theory has been advanced that, after 
a paralysis of the leg, the limb lies flaccid and nearly powerless, the 
toes drop, and, if the sitting posture is assumed, the knees flex and the 
legs hang heavily down. As a result of this, the anterior muscles are 
always pulled upon and slightly stretched, while the posterior ones are 
lax. If all the muscles are equally affected, this very factor may be 
enough to make a great difference in the ultimate usefulness of the two 
groups. Stretched muscles are notoriously at a disadvantage, so far as 

1 Bradford : "Etiology of Lateral Curvature," Boston Med. and Surg. Jour., 
1886, cxiv. 



4H 



ORTHOPEDIC SURGERY. 



recovery goes, in any diseased condition, and muscles at rest are much 
more favorably situated. So that this very point may determine in a 
measure the relative amount of recovery in the two groups. 

Moreover, muscular contraction and consequent deformity occur 
only in cases in which a muscle has been allowed to remain for a long 
time in a shortened or stretched condition. For this reason it is highly 
important to support and restrain 
the affected limb in a normal po- 
sition (the foot at a right angle 
to the leg, etc.). 

The common deformities from 
infantile paralysis which come to 
the orthopedic surgeon for treat- 





FlG. 369. 



Kyphosis in Advanced Paralysis 
of the Back Muscles. 



Fig. 370 —Infantile Paralysis. Contract- 
ures of right leg. (Weigel.) 



ment are those of the lower extremity. Considered in detail, it is best 
to begin with deformities at the hip-joint and then to pass on to the 
consideration of knee-joint deformities and distortions of the foot. 

Deformities of the Leg. — Paralysis may be complete and a flail-like 
leg be the result, with wasted muscles and loose, distorted joints, inca- 
pable of motion or bearing weight. Such a limb is spoken of as " jambe 
de Polichinelle." 

But more commonly the paralysis is partial rather than complete. 



ANTERIOR POLIOMYELITIS. 



415 



The muscles of the thigh commonly affected are the internal and ante- 
rior groups. This constitutes a serious combination and renders walk- 
ing difficult ; not only is the leg abducted with a tendency to eversion, 
but the extensor thigh muscles cannot hold the knee rigid as is neces- 
sary in walking, the leg giving way whenever weight is put upon it. 
The glutei are generally implicated in this paralysis, and the contraction 




FIG. 371.— Paralysis of the Left Leg, with Talipes Equinus and Involvement of the Internal 
Rotators and Abductors of the Leg, Resulting in a Position of Abduction and Eversion. 



which is likely to result from this paralysis is flexion of the thigh alone 
or with abduction of the leg, a condition always associated with flexion 
of the knee and talipes equino-varus. 

Flexion deformity at the hip produces in time a most marked lordo- 
sis in the back. When the patient stands with the leg dangling, the 
weight of it drags upon the pelvis and rotates it on a transverse axis, a 
compensation which makes it possible for the leg to hang as nearly as 
possible perpendicularly. This deformity is marked and troublesome. 



416 



ORTHOPEDIC SURGERY. 



At the knee, contraction in the flexed position (with often a ten- 
dency to subluxation of the tibia backward) is found, and in the more 
severe cases decided knock-knee. At other times when laxity rather 
than contraction predominates, hyperextension of the knee is observed 
and sometimes lateral mobility also exists. In severe cases of this type 




Fig. 



572. — Severe Double Paralysis with Marked Knock-knee and Distortion of Feet. This 
patient was unable to walk. 



in which the deformity has been rectified by mechanical or operative 
means, the tibia lies in a plane decidedly posterior to that of the femur. 
The same may be said of the knock-knee which results from the greater 
prominence of the internal condyle of the femur. The flexion may 
have been overcome, but still a decided degree of knock-knee may re- 
main in the corrected leg. 

Hyperextension of the knee may also increase to a very marked 
degree and is commonly associated with talipes valgus. This hyperex- 
tension results in cases in which the anterior muscles are weak and fail 
to hold the knee extended when walking is attempted. In these cases 
the patient throws the weight of the body upon the fully extended knee 



ANTERIOR POLIOMYELITIS. 



417 



and the strain falls upon the ligaments rather than on the muscles. 
The posterior ligaments yield in time to this repeated weight and the 
patient obtains for a time a better bearing. The same deformity is 
favored by a tendency which these patients have to lean with the hand 
upon the knee when rising from a chair. 

There is a tendency to outward rotation of the tibia upon the femur 
in cases of long-standing paralysis of the leg. In this case the eversion 
of the foot in walking is a troublesome complication. 

Inasmuch as paralyses of the anterior tibial muscles and the peronei 
are the most frequent, 1 the deformities that one sees oftenest are talipes 




Fig. 



573.— Hyperextension of the Left Knee due to Paralysis of the Limb. Varus deformity 

of the right foot. 



equino -varus, or, if the peronei are intact, talipes equinus. Pure talipes 
varus from this cause is not common. 

It will be seen that hyperextension of the knee is favored in cases in 
which talipes equinus exists, as by that means alone the foot can be 
placed flat on the ground. 

Talipes calcaneo-valgus and pure flat-foot are favored by lax liga- 
ments, and the latter may be a progressive deformity, which increases 
until a stage is reached in which the inner malleolus almost touches the 
ground and the foot can be flexed until the dorsum touches the skin 

1 Ross: " Dis. of Nerv. Syst. ," William Wood & Co., 1878, p. 942. 
27 



4i8 



ORTHOPEDIC SURGERY. 



over the tibia. The bearing of body-weight on a foot, the ligaments 
and muscles of which are weak, tends to produce flat-foot. 

Pure talipes calcaneus seems to be the result of the paralysis of the 
posterior calf muscles combined with the action of gravity and super- 
incumbent weight. What is 
known as pes cavus is more 
common than pure talipes cal- 
caneus. 

The order of frequency of 
the different forms of deform- 
ity from anterior poliomyelitis 
is as follows : (i) talipes equino- 
varus; (2) calcaneo-valgus ; (3) 
equinus; (4) calcaneus or pes 
cavus. 

Deformities of the arms are 
not common as the result of 
infantile paralysis. The least 
infrequent of these results from 
the paralysis of the deltoid. In 
addition to the inability to raise 
the arm from the side, there 
are present a flattening of the 
shoulder and a prominence of 
the acromion process, and the 
shoulder presents an angular 
rather than a rounded outline. 
The ligaments are loosened, and 
the arm hangs loosely, so that 
in some cases a wide gap may 
be observed between the acro- 
mion and the humerus. 

Any distortion of the arm 
and hand further than the 
flaccid condition resulting from the paralysis is quite rare. If con- 
traction does occur, it follows the type to be seen in adult hemiplegia : 
flexion of the elbow, hand, and fingers. The commonest paralysis of 
the hand is one affecting the adductor muscles of the thumb, as a re- 
sult of which the thumb is drawn back to a level with the other fingers 
and the power to oppose it to the other fingers in grasping is thus lost. 
Infantile paralysis of the sterno-mastoid muscle is recognized as an 
occasional cause of wry-neck. Paralysis of the intercostal muscles 
rarely causes deformity, but Gowers saw a case in which a permanent 
depression in one side of the thorax resulted from such a paralysis. 




FIG. 374.— Paralysis of Both Legs, Severest in 
Right. Knock-knee and flail -like legs. This 
patient was unable to walk without crutches. 



ANTERIOR POLIOMYELITIS. 



419 



Paralysis of the erector spinae muscles results in a permanent arching 
of the spine and inability to sit erect. Paralysis of the abdominal mus- 
cles causes lordosis. 

Lateral curvature of the spine results from infantile paralysis in one 
of three ways : 

(1) From the inequality in the length of the legs (due to paralysis 
of one leg), causing tilting of the pelvis. (2) From the unilateral paral- 
ysis of the muscles directly controlling the vertebral column, which 
might be either a paralysis of the intrinsic spinal muscles or of the 
erector spinae group on one side. (3) From faulty spinal attitudes as- 
sumed in consequence of some paralysis elsewhere, as in paralysis of 
one arm, or of the serratus magnus, or even of the sterno-mastoid. 
These cases have been more particularly considered under the head of 
lateral curvature. 

Dislocations from Infantile Paralysis. — Dislocation, complete or 
partial, belongs to the more uncommon of the complications of infantile 
paralysis and characterizes severe cases. 

Dislocation of the hip is the one most commonly met and it takes 
place either spontaneously or in consequence of weight being borne 




Fig. 



-Paralysis of the Back Muscles, Causing- Saddle- back Deformity. 



upon a limb which is improperly supported by its ligaments. It occurs 
chiefly in cases in which the paralysis is severe and of long standing, and 
it may disable the leg on account of the laxity with which the femur 
articulates with the pelvis. A shortening of one or two inches may be 
present, as the dislocation is generally on to the dorsum of the ilium ; 



420 



ORTHOPEDIC SURGERY. 



but sometimes it takes the form of a laxity of the joint in all directions, 
so that the head may be thrown into any position by manipulation of 
the shaft. Most dislocations of the hip are inconvenient chiefly be- 
cause of the shortening and insecurity which follow the displacement of 
the head of the bone. But the head 
of the bone in a year or two becomes 
often quite firmly fixed in its new 
position, and such legs are some- 





PlG. 376. 



-Paralysis of the Left Arm Muscles, Del- 
toid and Serratus Magnus. 



Fig. 377.— Moderate Degree of Talipes 
Valgus, Right Foot. 



times nearly as serviceable as they were before. Dislocation may, 
however, occur before any weight is borne upon the affected limb, by 
the spontaneous action of the muscles, as in a patient eighteen months 
old, in the experience of one of the writers, in which dislocation of one 
hip took place at the age of three months. In this case the dislocation 
was reduced under an anaesthetic, and by the application of a plaster- 
of-Paris bandage the head of the femur was permanently retained in the 
acetabulum. These dislocations are rarely attended by much pain and 
are often overlooked by the parents. 

Laxity of the knee-joint, so that the joint surfaces slip by each other 
in the motions of the joint, is a less common affection, but is sometimes 
seen. In these cases the joint is subluxated at each step. 



ANTERIOR POLIOMYELITIS. 



421 



The subluxation of the tibia in severe cases of knee flexion and the 
dislocation of the shoulder after paralysis of the deltoid muscle have 
been already mentioned. 

DIAGNOSIS. 

In typical cases the diagnosis of infantile paralysis is not difficult. 
But in other than typical cases the recognition of the disease may be 
extremely difficult, and it is never easy to establish a positive diagnosis 
in the initial stage. At that time the occurrence of localized pain may 
be a misleading symptom, and sensitiveness of the affected limbs may 
suggest rheumatism. The occurrence of convulsions and unconscious- 
ness may divert the attention to the brain, and all sorts of side issues 
may be suggested by the manifold symptoms of the onset of the disease. 
The affection is often wrongly classed as cerebrospinal meningitis at 
the earliest stage, as the head is sometimes drawn backward in severe 
cases. 

The diagnostic points upon which the practitioner must rely are the 
sudden onset, a motor paralysis, rapid muscular wasting, the distribu- 




FlG. 378.— Talipes Varus, Right Foot. 

tion of the paralysis (mostly monoplegic and very rarely hemiplegic), 
and the loss of the tendon reflex. Diagnosis by the determination of 
the electrical reaction of the muscles requires especial training and skill, 
although it is distinctive and the most reliable test at our command. 

Electrical Condition of the Muscles. — The electrical reactions in 
infantile paralysis are clearly marked and characteristic when they can 



422 



ORTHOPEDIC SURGERY. 



be obtained. Faradic irritability of the affected muscles and nerves 
begins to diminish within a day or two of the onset of the paralysis, and 
in muscles severely affected the electric irritability disappears entirely; 
in the muscles less seriously involved it is merely diminished. This 
constitutes a valuable symptom in prognosis, as in muscles which are 
completely paralyzed faradic irritability is permanently lost by the sec- 
ond week. But even in later years it may be possible to find in such 
muscles a trace of irritability to the faradic current by thrusting a hy- 
podermic needle into the muscular substance and transmitting the cur- 





FlG. 379. — Flexion Deformity of 
the Hip, Knee, and Ankle, due 
to Contractions. 



Fig. 380.— Dislocation of Hip, the Result of In- 
fantile Paralysis. In this position the head 
of the femur (left) is in place, but with ab- 
duction it slips out again. 



rent through that. But the change in reaction to the galvanic current 
is even more important. Normally when this current is passed through 
nerve and muscle, a quick, sharp muscular contraction takes place at the 
opening and closing of the current, and the muscular contraction 



ANTERIOR POLIOMYELITIS, 



42 3 



should be greater at the closing of the negative pole than when the 
positive pole is closed. The cathodal closing contraction should be 
normally greater than the anodal closing contraction. When nerves 
and muscles affected by anterior poliomyelitis are examined, not only a 




k 




Fig. 381. — Same Case as Shown in Fig. 
380, with Hip Dislocated. 



FIG. 382. -Old Paralysis of Left Leg with 
Slight Knock-knee and Talipes Varus. 



slow wave-like response to electricity instead of a sharp quick jerk is 
found, but the electrical formula is reversed and the closure of the posi- 
tive pole gives the greater contraction. In general a much stronger gal- 
vanic current is needed to produce a contraction in these paralyzed 
muscles than in normal ones. These qualitative and quantitative 
changes in reaction to the galvanic current constitute what is known as 
the "reaction of degeneration," and this affords the most definite 
ground for the diagnosis of infantile paralysis. But such an examina- 
tion to be of any value requires practice and special skill in the use of 
electricity. In young children the examination often yields no results 
even to a specialist in nervous diseases on account of the child's con- 
stant activity, and although it is the most definite means of diagnosis that 
we possess in obscure cases, its use is attended with many difficulties. 



424 



ORTHOPEDIC SURGERY. 



The only affection which may not be distinguished by electrical ex- 
amination from anterior poliomyelitis is peripheral paralysis caused by 
interruption in the course of some nerve. 



DIFFERENTIAL DIAGNOSIS. 

The leading points which are to be depended upon in the differen- 
tial diagnosis are these : Infantile paralysis is purely a motor affection 
and sensation is never permanently impaired. The reflexes are gener- 
ally diminished or lost. Wasting is rapid and extreme and the leg is 
cold and blue in severe cases. The " reaction of degeneration " is pres- 
ent in electrical examination. 

Cerebral paralysis generally begins with a sudden onset, and often 
convulsions are present and the child is found to have lost the use of 
one side of the body. It differs from infantile paralysis in these points : 
its distribution is hemiplegic and facial paralysis is common, the tendon 
reflexes are increased from first to last, faradic excitability is not lost, 
and the galvanic formula is normal ; later the intelligence is generally 
affected and atrophy is neither so marked nor so rapid as in infantile 
spinal paralysis, but similar contractions of the joints of the affected 
limb come on. These contractions are, however, often spastic in char- 
acter. Allusion must be made to the importance of electricity in mak- 
ing a differential diagnosis, which is often attended with much difficulty. 
A hemiplegic distribution of infantile spinal paralysis is rare, but cases 
have been reported in which the facial nerve was involved. 1 

Table of the Differential Diagnosis of Infantile Paralysis and 

Cerebral Paralysis. 



Age. 



Onset. 



Dis tr i bu t i on 
paralysis. 



of 



Reflexes. 
Electrical reaction. 



Mental impair- 
ment. 



Infantile Spinal Paralysis. 

Sharply limited to children in 
first dentition. 

Sudden, but severe convul- 
sions not often present. 

Oftenest monoplegia or para- 
plegia ; rarely involves fa- 
cial nerve. 

Lost generally. 

Faradism, diminished or lost. 

Galvanism, formula reversed 
(reaction of degeneration). 

Absent. 

Spastic condition absent. 



Cerebral Paralysis (Hemiplegia). 

Not sharply limited to young 
children. 

Sudden, and severe convul- 
sions generally present. 

Hemiplegia ; generally involv- 
ing facial muscles on one 
side. 

Increased. 

Faradism, normal. 

Galvanism, normal. 

Likely to come on. 

Spastic condition of one or 
both legs often follows. 



Progressive muscular atrophy in childhood is a very rare affection, 
but it has been observed, sometimes beginning in the legs. Its onset 
1 Henoch : Loc. cit., p. 203. — Barlow: Loc. cit, p. 76.— Seeligmiiller. 



ANTERIOR POLIOMYELITIS. 425 

is gradual, and the faradic excitability remains so long as there is any 
muscular substance left and the galvanic formula remains normal. The 
reflexes are not lost until all muscular substance has gone. 

Acute transverse myelitis of the dorsal region causes paralysis of 
the legs when it occurs, but unless the lumbar enlargement is involved 
there is no loss of electrical irritability. Reflex action after a day or 
two is much increased and ankle clonus can be obtained. There is 
generally paralysis of sensation, and bed-sores develop with much ra- 
pidity, while any wasting is very gradual. There is no change in the 
electrical formula. 

A paralysis much like that in anterior poliomyelitis has been de- 
scribed by Bullard following cerebrospinal meningitis} In such cases 
pain and tenderness of muscles persist longer than in infantile paraly- 
sis. There is a tendency to spastic contraction in the early stages, 
which becomes less later. The knee-jerks on the whole are less 
affected than in infantile paralysis ; they may, however, be absent en- 
tirely. 

Diphtheritic paralysis may offer serious difficulty in diagnosis, be- 
cause anterior poliomyelitis may occur in the course of a diphtheritic 
attack as in any other infectious disease. The paralysis of diphtheria 
affects oftenest the muscles of the palate and fauces, the electrical reac- 
tions remain normal, and severe atrophy is not present. 

Pseudohypertrophic paralysis in its early stages is not likely to be 
confused with infantile paralysis, for it is generally characterized by 
much increase in the size of the muscles, which is extensively distrib- 
uted and comes on very gradually and is not accompanied by any 
marked electrical changes. Late in the affection marked muscular 
atrophy occurs, but it is generalized and the history would clearly 
differentiate the condition from anterior poliomyelitis. 

Paralysis may result from lesions of a peripheral nerve, as in instru- 
mental delivery at childbirth, from tight bandaging, etc. But its dis- 
tribution is limited to a single nerve or group of nerves, and it is char- 
acterized by a concomitant affection of sensibility. The electrical 
reaction would be the same as in infantile paralysis. 

The so-called rhachitic paralysis might offer some difficulty of diag- 
nosis. But it occurs in the acute stage of rickets and is not a paraly- 
sis so much as a disinclination to use weak and tender limbs. It is 
accompanied by general tenderness and to a certain extent by the diag- 
nostic signs of rickets, the reflexes are normal, and its onset is more 
gradual. It is, however, so early a complication of rickets that its recog- 
nition may offer difficulty. 

Infantile paralysis of one leg may produce a limp in gait which sug- 
gests congenital dislocation of the hip, but only on a superficial exami- 
1 Boston Med. and Surg. Journ., vol. i., p. 159, 1899. 



426 ORTHOPEDIC SURGERY. 

nation. In congenital dislocation the trochanter would be above Nek- 
ton's line, atrophy would be very slight, and the electrical reaction 
normal. 

With hip disease \ infantile paralysis is at times confounded in prac- 
tice. The onset of the paralysis may be accompanied by joint pain and 
tenderness, and, on the other hand, hip disease is accompanied by mus- 
cular atrophy and a modification of faradic irritability of the muscles. 
But the distinguishing feature of hip disease is muscular fixation, and 
that is not present in infantile paralysis, in which muscular laxity is the 
prevailing condition. The onset of hip disease, although generally 
gradual, may at times be apparently sudden. 

PROGNOSIS. 

So far as clanger to life is concerned, the outlook in infantile paraly- 
sis is very favorable, for few patients die in the acute attack. When 
death does occur it is generally at the end of a week or ten days. Con- 
tinued cerebral symptoms, however, are of grave significance. In cases 
in which the deformity is only of moderate extent, it is not probable 
that life will be shortened by it. 

It is not likely that the paralysis will increase if it has been station- 
ary for twenty-four hours. Second attacks are very rare, and when 
they do occur, they come on within a day or two of the original attack 
and are made evident by an increase of the existing paralysis. 

The tendency of the paralysis, as we have seen, is toward improve- 
ment and partial recovery. The law of Duchenne suggests a more 
exact prognosis in the fact that all the paralyzed muscles in which the 
faradic irritability is only more or less diminished, but not completely 
lost, during the course of the second week, do not remain permanently 
paralyzed, the restoration being more prompt and complete the less the 
faradic irritability has been diminished. In general, when the faradic 
irritability is lost at once, paralysis will be severe and to a certain ex- 
tent permanent. When the irritability is lost later, the paralyzed mus- 
cles will improve slowly and nearly recover. When faradic irritability 
is not lost at all, recovery will take place in a few weeks or months. 
Without the use of electricity one has to wait much longer before giv- 
ing any more definite prognosis than a general promise of improve- 
ment. 

When untreated, a case of infantile paralysis will almost invariably 
improve for one or two months at a rapid rate, then more slowly for 
two or three months more, and then after a stationary period, contrac- 
tions, looseness of the joints, and malpositions are likely to begin, 
which may increase indefinitely. Under treatment the prognosis is 
much more favorable and the limit of possible improvement extended 
by many years. 



ANTERIOR POLIOMYELITIS. 427 

It should be remembered that even in mild cases of infantile paral- 
ysis bone shortening may follow. Certain severe cases escape with but 
little, while a mild case of talipes valgus may show, with the wasting of 
the leg, a shortening of one or two inches in the limb of the affected 
side, or, in exceptionally severe cases, shortening of several inches. 

A large measure of success in the orthopedic treatment of infantile 
paralysis in the stage of deformity can be expected in a large percen- 
tage of cases, exclusive of the hopeless class where a large portion of 
the body is permanently paralyzed. If correction of the deformity, 
mechanical treatment, massage, dry heat, and all practicable use of the 
limb aided by apparatus be begun at as early a stage as possible, devel- 
opment of the strength of many muscles not completely paralyzed, but 
weakened from disuse after the original onset of the disease, can be 
expected, materially benefiting the patient. This can be supplemented 
if necessary by tendon transference or arthrodesis. By thorough sur- 
gical care what would be a condition of hopeless affliction can be con- 
verted into a slight or endurable disability. 

TREATMENT. 

The treatment of infantile paralysis varies according to the stage at 
-which treatment is to be undertaken, and is either stimulative to check 
the paralysis, or corrective to prevent or improve deformity. For the 
latter purpose it is either mechanical or operative. 

The Stage of Onset. — If the fact that paralysis is present is estab- 
lished during the febrile attack, which is usually the first symptom of 
the disease, vigorous treatment should be at once begun, to limit, if 
possible, the destructive process in the cord. Cathartics should be 
given at once, the patient should lie on the side or the belly, to prevent 
.stasis of the blood in the spinal cord, and counter-irritants or cups 
should be applied over the spine. Ergot should be administered in 
doses of ten drops of the fluid extract, three times a day, for infants of 
six months, and half a drachm for children of one or two years. Bro- 
mide of potassium and of sodium and strychnia are recommended. 
The general condition of the child should in every way be kept as good 
as possible. Antipyretics may be indicated. 

The Stage of Paralysis. — But few cases are seen by the surgeon 
until the stage of paralysis is present, when treatment by medicine is 
manifestly of little avail. The question that then presents itself is in 
regard to the treatment of the paralysis, in order that the ultimate 
amount of muscular power may be as great as possible. It must be 
remembered that the tendency of the paralysis is at first very strong 
toward spontaneous improvement. It is therefore manifest that in the 
first few weeks treatment should be directed toward producing condi- 



428 ORTHOPEDIC SURGERY. 

tions which shall be as favorable as possible for that improvement* to 
attain its maximum. 

The object of treatment in this stage should therefore be, first, to 
support the affected limb in a normal position, and most carefully guard 
against the stretching of joints and ligaments and muscles; and, sec- 
ondly, by the use of electricity, massage, and systematic exercise to 
keep the nutrition of the affected muscles in the best possible condi- 
tion. In this way only, by beginning the treatment at the first, can 
the best possible ultimate result be obtained. 

It has been seen that what may be called protective treatment 
should be begun at once, and from the first the diseased limb should be 
placed and retained in a normal position, so that the affected muscles 
and joints maybe supported and kept at rest and relaxed. In this way 
the enfeebled muscles are placed under the best possible conditions for 
their recovery. To allow attention to be diverted from these very 
important measures to pursue a medical treatment whose utility is 
doubtful, is manifestly irrational. In paralysis of the legs the feet 
should be supported from the first at a right angle, in their normal posi- 
tion, by some simple splint or similar appliance, and the weight of the 
bed clothes should be kept off of the toes. 

The appliances needed to maintain in a proper position the limbs of 
a patient with paralysis will vary according to the parts affected and 
will demand some ingenuity on the part of the surgeon. In severe and 
extensive cases light bed frames may be very useful to allow the patient 
to be carried about, while retaining the limbs in a proper position. So 
far as possible in such cases bandages should be avoided, and straps 
should be used instead, as the surface circulation is feeble and likely to 
be impeded by bandages. 

When the arm is paralyzed, a sling should be worn to prevent drag- 
ging of the arm upon the shoulder-joint ligaments and the weakened 
deltoid muscle, or, if the deltoid is chiefly affected, the arm may be sup- 
ported on a frame holding it at right angles to the trunk. 

Electricity is a most useful therapeutic measure in the early stages 
of the paralysis. Treatment should be begun as early as the spinal 
irritation seems to have disappeared, probably about the end of the 
first week, and continued indefinitely, but not to the exclusion of proper 
mechanical treatment. The galvanic current is used ; a very gentle cur- 
rent is passed through the affected muscles and nerves for a few min- 
utes each day, and muscles which contract only feebly to faradism 
should be daily stimulated by the application of the faradic current. 
Muscles which will not contract to faradism can sometimes be much 
improved by applications of the interrupted galvanic current. The 
chief use of electricity, it is to be remembered, is to stimulate to con- 
traction the paralyzed muscles, thereby affording a sort of gymnastics. 



ANTERIOR POLIOMYELITIS. 



429 



Probably electrical treatment receives much credit in the treatment of 
this disease, which is not improperly due to it, for it is employed at a 
time when marked improvement is almost certain, and very much the 
same results can be obtained by methods about to be considered. One 
sees cases in which it has ceased to benefit the child and has been per- 
sisted in to the exclusion of more rational treatment for that especial 
case. But even in the late stages of the disease, when wasting and 
deformity have come on, the use of electricity may at times lead to an 
improvement of nutrition. 

Dry warmth and rubbing are measures which seem of equal, if not 
of greater, value in the stage of simple paralysis. Heat is easily ap- 
plied by having the child sit in front of a fire or stove with the leg 





^^k 


« 



Fig. 383.— Clawed Toes and Pes Cavus following Infantile Paralysis. 

thrust through a hole in a sheet of pasteboard. This serves as a screen 
to the rest of the body, while the affected member is allowed to become 
thoroughly warmed once or twice a day either in this way or by a hot- 
air oven. During the day, especially in cold weather, the paralyzed limb 
should be protected by two thick stockings and a warm boot. Any 
treatment which stimulates the circulation of the paralyzed limb aids 
in its recovery by improving the nutrition of the muscles, and dry heat 
very effectually accomplishes this end. A paralyzed leg should be 
thoroughly heated for an hour before it is rubbed at night. 

Massage is another most important element of treatment in this as 
in any stage of infantile paralysis after the initial irritation has quieted 
down. Skilled massage, when it can be obtained, is of course better 
than friction at the hands of the parents, but the latter is a simple and 
efficient treatment, which lies within the reach of most people. 

In the place of the usual manual massage, mechanical massage of 
the limbs has been employed by means of carefully constructed appli- 
ances. This, however, will be within the reach of but few. 



43° ORTHOPEDIC SURGERY. 

Active muscular exercise of the paralyzed limb is a most desirable 
tonic to the affected muscles, however it is obtained, provided the mus- 
cles be not overtaxed. With the assistance of the parent's hand, afoot 
which naturally drops forward from paralysis of the anterior leg mus- 
cles can be flexed, and with each repetition of the exercise the muscle 
may be found able to accomplish more. It is impossible to lay down 
any series of exercises. In each case the problem must be met differ- 
ently. The aim should be so to assist the affected muscles that if they 
have any power left they may be enabled to use it daily for their own 
advantage. And with this in view, assistance should be rendered by 
supporting and aiding the affected limb in its movements in the way 
most likely to call into use these paralyzed muscles. Such exercise 
forms a most useful adjunct to the massage. It should be repeated 
each night just before or just after the massage. 

H. L. Taylor, in an excellent paper on the hygiene of reflex action, 
says : " In the neuromuscular degenerations following acute anterior 
poliomyelitis, it is especially important to restore to the paretic extrem- 
ities, so far as possible, the stimuli of locomotion and other normal 
associated movements without the inhibition of insecure footing and 
strained tissues — and it is for the specific purpose of restoring to the 
damaged cord and muscles the cutaneous, muscular, and articular stim- 
uli of locomotion that apparatus is constructed." 

Mechanical Treatment. 

The mechanical treatment of infantile paralysis is twofold in its ob- 
ject. The first and simplest use of apparatus is to support and protect 
the paralyzed limb in such a way that the muscles shall work to the 
best advantage and that the joints may be supported and controlled. 
By doing this the occurrence of contraction deformities is prevented 
and the nutrition of the limb is kept in the best possible condition by 
enabling the limb to be used in a comparatively normal way. 

The second function of mechanical treatment in infantile paralysis 
is to overcome by means of suitable appliances deformities which have 
already occurred and to prevent their recurrence ; it may often be nec- 
essary to attempt both objects with one apparatus. 

The Indications for Mechanical Treatment. — Whenever a paralyzed 
limb is unable to bear the weight of the body which falls upon it in 
locomotion, some mechanical help is manifestly advisable. This is not 
only needed when the paralysis is complete, but also when, owing to 
incomplete muscular strength, more strain is borne on the articular lig- 
aments than is normal. Moreover, when the bearing of the body-weight 
or the act of walking throws the foot or the leg into any abnormal po- 
sition, the use of some appliance is indicated. It is difficult to describe 



ANTERIOR POLIOMYELITIS. 43 r 

the various appliances needed in the treatment of infantile paralysis, 
and much must be left to the ingenuity of the surgeon in each case. 

Paralysis of the Leg. — When the muscles of the leg are paralyzed, 
those which help to control the ankle-joint in standing and walking are 
rendered inefficient and the ligaments may become relaxed, so that in 
the standing position the ankle of the affected side cannot sustain the 
body-weight as it should, and the foot is apt to roll in or out, causing 
an inversion or eversion of the foot amounting to a degree of talipes 
varus or valgus. 

In any apparatus which is to sustain the foot in its weight-bearing 
function, accuracy of support is indispensable, and a simple leather 
boot, however stout it may be, soon yields and the foot slips away from 
the rest of the apparatus, and the efficiency of the brace is impaired ; a 
rigid sole is, therefore, essential for any apparatus which is to control 
the ankle properly, and this can easily be accomplished by having a. 
thin steel plate inserted between the layers of the sole of the boot. 

When no contraction or deformity exists at the ankle, but there is 
simply a tendency of the front of the foot to drop on account of the 
affection of the anterior muscles of the leg, locomotion can be made 
much more easy by preventing this. A common appliance for this lat- 
ter deformity is an ordinary shoe fitted with lateral steel uprights and 
a posterior steel calf band (Chapter XXL, 28). There is a right-angle 
stop catch at the ankle which keeps the foot from dropping. 

The same end can be better accomplished by the application of a 
walking appliance, described under club-foot as an equino-varus shoe, 
which should be provided with a right-angle stop at the ankle which 
will not allow the ankle to be extended to more than a right angle 
(Chapter XXL, 27). When in bearing weight upon the leg the ankle 
assumes a varus position, a varus shoe will correct the tendency to de- 
formity (Chapter XXL, 30). 

If the foot rolls out and is everted into a valgus condition when the 
body weight is borne upon the leg, an outside shoe is to be applied, in 
construction like the varus shoe, but which should have a broad leather 
strap which should pass around the inner malleolus and support it 
(Chapter XXL, 31). This apparatus is a difficult one to render quite 
comfortable to the patient, as much weight must necessarily come upon 
the strap which supports the inner malleolus. As flat-foot is almost 
always present in these cases, it is well to arch the steel sole plate of 
this apparatus so that it serves as a valgus plate as well as a support- 
ing appliance. 

If calcaneus is present the apparatus spoken of for equinus is used, 
with the stop catch reversed to prevent dorsal instead of plantar flexion 
(Chapter XXL, 29). 

Pes cavus may be treated by inserting a steel sole in the sole of the 



43 2 ORTHOPEDIC SURGERY. 

boot and passing a strap from the sole over the dorsum of the foot. 
This treatment is made much more efficient if combined with prelimi- 
nary division of the plantar fascia. Mechanical treatment alone is 
likely to be unsatisfactory. 

Talipes calcaneus may be treated by fixing the foot for months in 
a position of talipes equinus by means of a plaster bandage. At the 
end of this time a shortening of the muscles at the back of the leg will 
be found. 1 

It is manifest that the simpler and lighter these appliances are and 
the less unsightly, the more serviceable they will prove. For this rea- 
son they should be carefully fitted and the uprights made to follow the 
outline of the leg. In very slight cases, in which there is only a slight 
eversion of the foot with a small degree of valgus, a common valgus 
plate (Chapter XXI., 32), such as would be applied for flat-foot, will 
often answer every purpose in correcting the deformity, and it should 
be applied as in simple flat-foot. 

In severe cases of paralysis of the muscles of the legs and foot, the 
thigh muscles may be involved. The same appliance will often have to 
support the knee and thigh as well as to correct deformity at the ankle. 
But this involves merely an extension of the apparatus up the leg. 

Paralysis of the Thigh Muscles. — When the muscles of the thigh 
are involved in the paralysis, the limb becomes unable to sustain the 
weight thrown upon it and the knee flexes and the limb drops forward 
when weight is borne upon it. The knee-joint does not bend to one 
side or the other, as the lateral ligaments retain much strength. In a 
few instances the knee will drop backward to more than a straight line, 
but, owing to the strength of the crucial ligaments in infantile paraly- 
sis, it never falls so far back as to be unable to sustain weight. For the 
practical purposes of locomotion, therefore, it is only essential that the 
knee be prevented from dropping forward, and this can be done by 
means of any appliance which will press the knee backward. The sim- 
plest way of doing this is by the use of two steel rods reaching from 
the back of the thigh to the bottom of the shoe (Chapter XXI., 25), 
connected at the top by a posterior steel band, which furnishes a coun- 
terpoint of pressure by which to hold the knee. If a strap is passed in 
front of the knee, it is impossible for it to drop forward when weight is 
thrown upon the leg, and the patient can stand upon the limb. The 
appliance supplies the check normally exercised by the muscles. Be- 
low it should be fitted to a boot, or, if the muscles of the leg are also 
involved, to one of the appliances such as the varus or valgus shoe men- 
tioned above. 

Instead of being applied by means of a steel sole plate, the appara- 
tus may be fastened to the sole of the boot (Chapter XXL, 26). In 
1 Gibney : Medical News, 1900, lxxvii., 399. 



ANTERIOR POLIOMYELITIS, 



433 



addition to the bands shown in the figure, leather lacings to retain the 
thigh and calf will probably be needed to give the apparatus greater 
stability, as the lacings, by covering a large area of skin, substitute sur- 
face pressure for the point press- 
ure given by narrow straps. 
This is a matter to be considered 
in all supporting apparatus. 





Fig. 384.— Supporting Splint for Infantile 
Paralysis of the Leg. 



Fig. 385.— Supporting Splint for Use in In- 
fantile Paralysis. It prevents flexion of 
the knee in standing, but is provided with 
a lock-joint at the knee. 



If the knee tends to drop backward and become hyperextended, it 
can be remedied by a similar appliance with a strap passing behind the 
knee, with an upper band encircling the thigh. In practice this appa- 
ratus can often consist of a single outside upright hinged at the knee. 
It passes to the inside of the leg just below the knee to become 
attached to a varus shoe. This answers as well as a double upright in 
28 



434 



ORTHOPEDIC SURGERY. 



many cases. The apparatus can be hinged at the knee for convenience 
in sitting down and should be furnished with leather lacings for the 
thigh and calf (see Figs. 384 and 385). 

Other cases, in which the paralysis is more severe, require the two 
uprights, as they furnish a more definite support. The foot is easily 




Fig. 



-Jacket Attached to Caliper Splints Applied to a Case of Paralysis of the Trunk 
and of Both Legs. 



retained to the steel sole plate by straps or a piece of leather lacing 
over the instep. The fenestrated knee cap is the most comfortable 
method of holding the knee extended. 

Although in walking it is generally necessary to have the knee kept 
extended by the splint, yet in sitting down it is a great comfort to the 
patient to be able to flex the knee, and for this reason nearly all splints 
should be hinged at the knee. 

A great variety of hinges can be applied at the knee with different 
catches, enabling the patient to bend the limb by loosening the catch 
or locking it when it is desired that the limb should be stiff. The sim- 
plest and most economical of these is the simple drop catch shown in 
the figure. When the limb is straightened, the ring falls down and 



ANTERIOR POLIOMYELITIS. 435 

locks the splint in the extended position, but it can be pulled up at any 
time, allowing the knee to bend. 

In another and more expensive form the splint is self-locking, and 
the bending is made possible by pressing a handle at the outside of the 
knee. 

When the adductor muscles are affected, little or nothing can be 
done to supplement them by mechanical means without employing 
heavy apparatus, inasmuch as their loss of power occurs only in exten- 
sive paralysis. Little can be done to remedy paralysis of the glutei 
muscles, but when paralysis of the legs appears to be complete, a cer- 
tain amount of relief may be given by attaching the leg uprights to a 
leather or silicate jacket. The common Thomas knee splint (Chapter 
XXL, 14) may be joined to a leather jacket (Chapter XXL, 3) by lat- 
eral uprights jointed at the trochanters. 

The muscles of the back are rarely if ever paralyzed, except in con- 
nection with palsy of some of the muscles of the leg. Complete paral- 
ysis of the muscles of the trunk indicates an extent of disease which is 
most distressing. When the muscles of the back are but partially 
affected, help may be afforded by the use of corsets or other supporting 
appliances, such as are employed in the deformities of the spine. 
These can be connected with the leg appliances and will afford assist- 
ance in standing. Cases of this sort may be so severe as to require the 
use of crutches for rapid locomotion, but much assistance may be 
afforded by appliances in many cases. 

The abdominal muscles are sometimes, though rarely, affected, giv- 
ing a protuberant abdomen and a position of much lordosis in standing. 
Waist bands or corsets will serve to correct the malposition of the 
trunk to a certain extent. 

The mechanical treatment of infantile paralysis of the arm is not a 
question which arises often enough to make it worth while to enter 
upon any discussion of it, save to mention that the principles of treat- 
ment are the same as those already considered. 

The use of elastic bands to supply the place of the disabled muscles 
is thought in some instances to be sufficient to compensate for the 
action of the paralyzed muscles. It will, however, be found that an 
elastic support, inasmuch as it is not of certain tension, is necessarily a 
varying support and adds to the complicated nature of the appliance 
rather than to its efficiency, nor is it possible to gauge accurately the 
force or pressure exerted at any time. It is generally, therefore, a 
much less efficient form of apparatus than the rigid forms here advo- 
cated. 

Mechanical Treatment as Applied to the Correction of the Deformity. 
— Whether the deformity shall be corrected by purely mechanical 
means or by operative interference depends not only upon the nature 



436 



ORTHOPEDIC SURGERY. 



of the distortion, but also upon the time at the disposal of the patient 
and surgeon. Many of the distortions of this sort can be cured in chil- 
dren without any operative interference, as all that is required is the 
stretching of the fasciae and the contracted tendons. These distortions 
are either flexions at the hip or knee or some distortion of the ankle. 
The less severe of these distortions yield readily upon the application 
of efficient force. 

Deformity at tJie hip, which is generally flexion, with perhaps abduc- 
tion, is the hardest of all the deformities of infantile paralysis to correct 
by mechanical means, on account of the difficulty of securing a fixed 
hold upon the pelvis, by which a point of resistance can be secured in 
overcoming the flexion of the thigh. A simple apparatus which is 
often of use is furnished by two caliper Thomas knee splints (Chapter 
XXI., 15), or one, as the case may be, attached to a leather jacket by 
side irons hinged opposite to the hips. To the posterior and upper 
parts of the splints are attached straps which buckle to the back of the 





Fig. 387. Fig. 388. 

FlGS. 387 and 388.— Supporting Apparatus in Paralysis of Anterior Thigh Muscles. 

jacket, and while by the jacket as firm a hold as possible is taken on 
the pelvis, when the straps are buckled the caliper splints pull the legs 
backward and tend to overcome the flexion at the hips. During this 
time the child should go about on crutches. 

But the contraction is sometimes resistant, and it is necessary to 
confine the patient to the bed and to employ traction of a considerable 
amount and such measures as have already been described in correc- 
tion of the flexion deformity of hip disease. 



ANTERIOR POLIOMYELITIS. 



437 



Attempts to use the weight of the leg to correct this flexion in se- 
vere cases are of little use. It might be imagined that if the knee were 
straightened by a ham splint, and the patient allowed to go about on 
crutches with the leg projecting in front of him, the weight of it by 
dragging upon the shortened tissues would stretch 
them and the flexion at the hip would be dimin- 
ished. But the leg hangs almost perpendicu- 
larly in these cases, owing to a compensatory 
lordosis in the lumbar spine, which takes place at 
once. This is due to the rotation of the pelvis 
upon its transverse axis, which occurs under the 
influence of the weight of the leg and which oc- 
casions no inconvenience to the patient. A sim- 
ilar proceeding occurs when a weight is applied 
to the patient's leg lying in bed, so that it be- 
comes inefficient also. In the severer cases op- 
erative treatment is indicated. 

Flexion of the knee is due to a contraction of 
the hamstring muscles. The deformity in chil- 
dren, except in severe cases, can be corrected by 
bandaging the leg to a splint which takes press- 
ure above on the under side of the thigh and 
below is fastened to the heel. The appliance is 
similar to that described above as a support to 
the knee. In resistant cases some pain is expe- 
rienced in this procedure, but the pain is not 
great. Patients with severe deformity should be 
confined to bed during the application of this 
method of treatment, but in the milder cases they 
may be allowed to go about. 

The simplest of all forms of correction in contraction of the knee is 
the Thomas knee splint (Chapter XXL, 14) or a modification of it, but 
jointed splints will be found convenient in some instances of the sever- 
est type. If the Thomas knee splint is applied, a bandage should be 
applied in front of the thigh and behind the calf ; by tightening these a 
decided extension force is exerted upon the knee. 

A more complicated brace for correction of the knee is one similar 
to the simple supporting brace with two uprights already described 
(Chapter XXI., 26), except that it is jointed at the knee and furnished 
on one side with a worm screw and ratchet, so that by the use of a key 
the splint can be set with any desired angle at the knee. A leather 
knee cap is sometimes necessary to obtain counter-pressure against the 
knee in front, but in other cases the thigh and calf lacings are sufficient 




Fig. 389.— Splint with Sin- 
gle Upright for Infantile 
Paralysis of Right Leg 
with Varus Deformity of 
Ankle. 



to obtain any desired leverage. These 



leather lacings 



should fit with 



438 ORTHOPEDIC SURGERY. 

especial accuracy in this form of appliance. To be applied the splint 
should be flexed to fit the contracted knee and put on and laced firmly. 
Then with the key it should be extended nearly to the point of endurance 
and worn as straight as it can be borne for an indefinite time. At first 
these sub-joints may prove sensitive and painful, but they soon become 
used to the tension and then rapid progress can be made. The exten- 
sion of a contracted knee may in the case of an adult be a matter of 
many months, but in children it requires less time, unless it is severe, 
when operation may be required. The deformity shows a strong ten- 
dency to recur when the apparatus is removed. 

Correction by the repeated application of plaster bandages to the 
knee, extended as much as possible, will often be found satisfactory 
and painless to the patient. This can be facilitated by inserting a 
hinge joint in the plaster at the knee, and by cutting away the plaster 
around the leg at the level of the hinges it may be used as a straight- 
ening appliance. The method, however, is a slow one in resistant de- 
formities. 

Deformities of the Feet. — The mechanical correction of deformities 
of the foot caused by infantile paralysis is so much more tedious than 
when operative measures are used that the majority of surgeons much 
prefer the latter method. In the less resistant cases, however, correc- 
tion of paralytic cases can be effected by plaster-of-Paris bandages re- 
peatedly applied to feet forcibly held in as near a corrected position as 
possible. Slight paralytic deformities of the feet can also be corrected 
by fixing the feet in the walking appliances used for the various forms 
of talipes, arranged so as to prevent motion in the direction of contrac- 
tion, but allowing motion in other directions. The weight of the patient 
at every step acts as a correcting force. 

OPERATIVE TREATMENT. 

The object of operative interference in paralytic affections is two- 
fold: 

i st. To correct existing deformity. 

2d. To render the paralyzed limb more efficient. 

For average cases of post-paralytic deformity, forcible manual cor- 
rection with or without the aid of tenotomy, with muscle-stretching 
and perhaps fasciotomy, are sufficient for correction. The deformities 
to be corrected are flexions at the hip and knee, and the distortions of 
the feet classed as the different forms of talipes. The latter can be 
corrected by the various procedures described in the chapter on " Club- 
foot." Paralytic talipes, however, is much less resistant and yields to 
much less radical measures than are often needed in congenital club- 
foot, and subcutaneous tenotomy and fasciotomy with manual correc- 
tion will suffice in almost all cases. 



ANTERIOR POLIOMYELITIS. 



439 



Flexion at the knee may require tenotomy of the hamstring muscles, 
which is more thoroughly performed by means of an open incision than 
subcutaneously, as frequently the shortened fasciae need division as 
well as the tendons. In order to prevent a gaping wound after correc- 
tion, a Y-shaped or longitudinal skin incision should be used. 

An open incision is necessary if the contractions in flexion of the hip 
are resistant. These are usually superficial and involve the fascia lata, 

but the intramuscular septa of the deep mus- 
i \ cles may also need division and the operation 

\ \ \ may have to be extensive. In the older cases 

in which alteration in the shape of the bone 
exists, osteotomy or even excision may be 
needed. The latter is rarely indicated, as 
linear osteotomy near the joint will enable 






Fig. 390.— Transplantation of 
Sartorius to Quadriceps 
Tendon. (Goldthwait.) 





Fig. 391.— Elongation of Tendo Achillis. (Berger and 
Banzet.) 



the surgeon to straighten the limb with less destruction of tissue. The 
measures above mentioned do not aid the paralysis, but aid locomotion 
with or without the necessary appliances. 

Tendon Transference. 1 — Measures maybe undertaken for the direct 

1 0. Vulpius: "Die Sehneniiberpflanzung," etc., Leipsic, 1902 (with bibli- 
ography). 



440 ORTHOPEDIC SURGERY. 

purpose of aiding the paralyzed muscles with the view of making loco- 
motion possible without the need of appliances. The most important 
of these are the operations on the affected muscles. 

Tendon transplantation or tendon anastomosis, first introduced in 
1 88 1 by Nicoiadoni, consists of a procedure by which the proximal ends 
of healthy or partially affected muscles are inserted in or attached to 
the distal ends of the tendons of paralyzed muscles or to the perios- 
teum, and the action of the healthy muscle is transferred to the attach- 
ment of the paralyzed one or to a more efficient insertion. 1 

The transference of one tendon to another, as originally intro- 
duced, has been extensively employed and has been followed by a cer- 
tain amount of success, but in a large percentage of cases the ulti- 
mate results have not been so beneficial as is to be desired. It was 
found that the functional strength of the transplanted muscle was 
rarely equal to the required work. Improvements in the methods have 
been made recently, however, which have increased the efficiency of the 
procedure. 

Periosteal tendon transference, as it may be termed, is a pro- 
cedure which can be relied upon to give a reasonable amount of perma- 
nent success. It is impossible at present to give the statistical value 
of the procedure. So much depends upon the amount of strength re- 
maining in the transferred muscle that the cases are difficult to group. 
For success it is essential that the muscular balance in the paralyzed 
limb be restored, and for this it is necessary that the transferred mus- 
cle pass as directly as possible from its origin to its new insertion ; it is 
essential that the transferred muscle should not be relaxed and that it 
should have a firm and an effective attachment. The transferred ten- 
don should be given a periosteal attachment, if possible, at such a point 
as will give on muscular contraction the functional result of the re- 
quired motion. When the tendon is not long enough to reach to the 
desired point of insertion, it can be lengthened by the use of strands of 
braided silk, which are quilted in the end of the transferred tendon, and 
at the distal end sewed into the periosteum or attached to the proximal 
end of the paralyzed tendon. 

Lange, who originated this method, has demonstrated not only that 
in this way a permanently useful tendon can be furnished, but that ap- 
parently fibrous tissue forms about the silk strands. The application 
of the method varies necessarily with the deformity and the part para- 
lyzed, whether it is for a paralytic talipes equino-varus, a valgus, equi- 
nus, calcaneus, for paralysis of the extensor cruris, or for other paral- 
yses. 

In equino-varus, cquino-valgus, or equinus the procedure is some- 

^odivilla: Zeitsch. f. orth. Chir., xii.— Vulpius : Ibidem. — Lange, Schanz, 
and Reiner: Ibidem.— Koch: Munch, med. Woch., July 19th, 1904. 



ANTERIOR POLIOMYELITIS. 



441 



h 



what the same. The operation is more conveniently done after the 
limb has been made bloodless by the Esmarch method, and the deform- 
ity of varus, valgus, or equinus must be forcibly corrected with tenoto- 
my and fasciotomy if necessary. The correction of the deformity 
should be preferably done a few days before the tendon operation. A 
long incision is then made over the middle of the ankle or the part of 
the ankle where the tendons to be operated on are situated, extending 
to the dorsum of the foot. The muscle to be transferred is then se- 
lected and the tendon isolated and cut off as near its insertion as possi- 
ble. The end is then secured by a long, 
stout, silk suture. The muscular portion 
is freed above sufficiently to permit a 
transferrence of the direction of the mus- 
cle in a nearly straight rather than a 
curved course. The desired point of in- 
sertion is then selected, which should be 
as far forward on the tarsus as is prac- 
ticable. The silk attached to the freed 
tendon is then stitched securely to the 
periosteum at the selected point, the 
tendon pulled tightly into its new posi- 
tion, and firmly tied. If the tendon is 
too short to reach, its length can be 
pieced out by the strong silk strands of 
the suture or it may be stitched into the 
paralyzed tendon near its insertion, but a 
periosteal insertion is much to be pre- 
ferred. All the extensor tendons of the 

foot, if relaxed, whether paralyzed or not, are to be shortened. If they 
are paralyzed they can be used as a stay in the corrected position, and 
if not paralyzed they can only be effective if sufficiently tight. The 
terdo Achillis should, of course, be divided when necessary. 

It is evident that the length and the site of the skin incision varies 
with the surgeon's judgment and with the muscle to be transferred. 
Whether the tibialis anticus or the peroneus longus is selected depends 
upon the location of the paralysis and will affect the position of the 
skin incision. When the anterior group of muscles are all paralyzed, 
as in talipes equinus, a portion of the tendo Achillis and one of the pe- 
ronei can be brought forward to the front of the foot and given an an- 
terior attachment on the tarsus. In this procedure a posterior as well 
as an anterior incision is needed, and the transferred tendon is passed 
subcutaneously forward from the posterior to the anterior incision. 

The operative reduction of calcaneus or calcaneo-valgns is not per- 
manently accomplished by simple shortening of the tendo Achillis, be- 




FlG. 392. 



Fig. 393. 



Fig. 392. — Transplantation of Ten- 
don. (Berger and Banzet.) 

Fig. 393.— Side Incisions in Tendon to 
Permit Elongation without Loss of 
Continuity. (Berger and Banzet.) 



442 ORTHOPEDIC SURGERY. 

cause, being paralyzed, the tendon will again stretch and the deformity 
recur. If the posterior part of the os calcis is set up toward the ankle, 
a better relation of the foot to the leg is obtained. The operative pro- 
cedure is as follows : The side of the os calcis is exposed by an incision 
sufficiently long and an osteotome is used to loosen the posterior part 
of the os calcis from the front part. The line, of separation begins 
above, just posterior to the astragalus, and runs downward and forward 
obliquely. When this part is separated the heel is set up by pressure 
on the tuberosity of the os calcis. The tendo Achillis is then exposed 
and reefed until it is tight with the foot in its corrected position. 

. If an element of valgus exists with the calcaneus, some of the ten- 
dons of the common extensor should be cut and given a periosteal in- 
sertion into the scaphoid or cuneiform. It may also be advisable to 
change the insertion of one of the peronei muscles to the inner border 
of the foot. 

In pes cavus the plantar fascia is to be tenotomized, the foot forci- 
bly stretched, with an osteotomy of the tarsus in extreme cases. Oste- 
otomy of the os calcis is also to be considered in pronounced varus and 
valgus with distortion of that bone. The proceeding is similar to that 
in congenital club-foot. 

Paralysis of the Extensor Cruris. — This paralysis can be improved if 
the hamstring muscles are sufficiently strong. The tendon of the bi- 
ceps (or a portion of it) and the semimembranosus are freed near their 
attachments by incision at both sides of the leg, and are brought for- 
ward under the skin and stitched securely into the ligamentum patellae 
close to the patella. It is necessary that the muscles should be freed 
sufficiently high up from their attachments so that the muscles can be 
brought to the front of the leg without being curved. 

Transplantation of the sartorius into the conjoined tendon of the 
quadriceps can be performed, but, as the muscle is not a strong one, as 
much effective strength cannot be expected from its transferrence as 
from that of the hamstring. This procedure sacrifices a portion of the 
power of flexion of the limb at the knee — a loss which is compensated 
for by the greater usefulness of the limb. 

Paralysis of the Upper Extremity. — A portion of the trapezius can 
be transferred to the insertion of the deltoid in paralysis of the latter. 
Tendon transferrence in paralysis of the wrist is of value. The same 
principles of procedure are necessary in the upper as in the lower ex- 
tremity. 

It is almost needless to state that suppuration diminishes the pros- 
pect of benefit from tendon and muscle transplantation, and the meas- 
ure should not be undertaken except by an adept in thorough asepsis. 

After-Treatment. — After the operation the limb should be protected 
by sufficient cotton padding and fixed in the desired corrected position 



ANTERIOR POLIOMYELITIS. 443 

in a plaster-of -Paris bandage, arranged so as to allow the required in- 
spection after dressing. After six weeks the plaster bandage is to be 
followed by a retention apparatus, such as has already been described, 
and the gradually increasing use of the limb allowed, along with mas- 
sage and passive exercises to develop the transferred muscles to their 
new work. 

Arthrodesis. — Where the paralysis is total or nearly so tendon trans- 
ference is useless, and the disability of the limb, except by mechanical 
assistance, would be unavoidable were it not for the procedure of ar- 
throdesis, which is devised for the purpose of stiffening the flaccid 
joint. This is more commonly applied to the ankle-joint and is at- 
tempted by opening the joint freely and exposing the astragalus, which 
should be denuded of cartilage on all its articular surfaces, as well as 
the lower end of the tibia and fibula. It is necessary that the os calcis 
should not be free to move under the astragalus, and the joint surfaces 
of the calcaneocuboid articulation are also to be denuded in very lax 
joints to prevent a subsequent distortion from the loosening of that 
joint. 

In cases of severely relaxed ankle-joints it is of use to shorten the 
anterior or other groups of muscles, in order to have them serve 
as stays to the newly stiffened joint in its resistance to strain. 

Arthrodesis can be employed in stiffening the knee and has been 
employed to fix the shoulder and hip. In the latter joint, however, the 
operation has hitherto been of doubtful benefit. 

After operation the joint should be fixed in a correct position for 
two months, after which gradually increasing use is to be allowed. 

Nerve-Twisting. — It is possible in some cases, where very slight 
power remains in some muscles of a limb, to increase and distribute that 
power better by a division and twisting of the main nerve of the limb. 

The nerve is dissected out and sutures are passed through the sheath 
in such a way that, when they are tightened after the nerve is cut, the 
distal end is rotated on the proximal end through one-third of a circle. 
The nerve is cut after the sutures are passed, the sutures are tied, and 
the wound is closed. Decided improvement in function has been re- 
ported. 1 

Nerve Transplantation. — It has been demonstrated experimentally 
by Spitzy 2 that nerve impulses may be given new directions by nerve 
anastomosis ; that is, connecting the proximal end of one nerve with 
the peripheral end of another and transferring its motor impulse. 
Peckham 3 transplanted in two cases two branches of the internal pop- 
liteal nerve into the external popliteal ; in both cases there was some 

'Verbal communication from Dr. W. S. Baer, of Baltimore. 
-American Jour. Orth. Surgery, August, 1904. 
3 Providence Med. Journal, January, 1900. 



444 ORTHOPEDIC SURGERY. 

restoration of power in the extensor muscles. J. K. Young, of Phila- 
delphia, 1 has since reported a case of successful nerve transplantation 
in the leg. 

The technique has been elaborated experimentally by Spitzy. 2 

Osteotomy may .be required to correct severe flexion deformity at 
the hip, and at the knee to correct the knock-knee and flexion at the 
same time. At the hip it does not differ from the ordinary Gant oper- 
ation, and is necessary only in cases in which division of the soft parts 
is not enough to allow sufficient extension of the thigh on the pelvis. 

At the knee a simple transverse division of the femur is made just 
above the condyles, allowing correction of both flexion and knock-knee 
at the same time. These operations, of course, have no effect upon the 
paralysis as such, but merely serve to place the limb in a position suit- 
able for weight-bearing. After operation mechanical support is usually 
necessary. 

Excision. — In other cases resection of joints is to be considered on 
account of the extreme bony deformity which they present, as in severe 
paralytic knock-knee, in which a stiff knee rather than a movable one is 
desired. If the latter is preferable an osteotomy rather than excision 
should be done, as excision leaves a stiff joint. The deformity of 
knock-knee or flexion at the knee can, of course, be corrected by the 
plane of the bone section in excision. 

1 Am Journ. Orth. Surg., August, 1904. 
' 2 Zeitsch. f. orth. Chir., xiii. 



CHAPTER XV. 
SPASTIC AND OTHER PARALYSES. 

Spastic paralysis. — Congenital. — Acquired. — Symptoms. — Idiocy. — Etiology of ac- 
quired spastic paralysis. — Pathology. — Diagnosis.— Prognosis. — Treatment. — 
Pseudohypertrophic paralysis. — Progressive muscular atrophy. — Hereditary 
ataxia.— Obstetrical paralysis. 

SPASTIC PARALYSIS. 

The condition is known under the following names : Spastic paraly- 
sis, spastic hemiplegia, Little's disease, spastische Gliederstarre, etc. 
The affection is more common than was formerly supposed. At the 
Children's Hospital 310 cases of cerebral paralysis came under treat- 
ment, while 987 cases of infantile paralysis appeared during the same 
period. 

Motor disturbances in children which are due to cerebral lesions 
are manifested clinically in one of three ways: (1) As a single hemiple- 
gia; (2) as a diplegia; (3) as a paraplegia. Contractures, choreiform 
movements, mental impairment, aphasia, epilepsy, inco-ordination, etc., 
may be the accompaniments of any one of these forms. 

The distribution of paralysis in 225 cases analyzed by Peterson and 
Sachs was as follows: Right hemiplegia, 81 ; left hemiplegia, 75 ; diple- 
gia, 39; paraplegia, 30. Total, 225. 

Congenital Spastic Paralysis. 

It is usually not recognized at birth, as it consists of a lack of mus- 
cular co-ordination common in infancy, which persists in certain mus- 
cles during life. The origin of it is to be found in cerebral defects, 
intra-uterine cerebral hemorrhage, and lack of development of the 
brain. 

Acquired Spastic Paralysis. 

Symptoms. — The form most commonly seen is that acquired during 
or after labor. The onset may resemble very closely that of infantile 
spinal paralysis; it often begins with an illness of some sort. Fre- 
quently paralysis develops in the course of an infectious disease, some- 
times after an attack of what seems to be indigestion or a slight 
feverish attack, sometimes after a fall or a slight blow on the head. 

445 



446 



ORTHOPEDIC SURGERY. 



Commonly the onset is marked by convulsions. Delirium or screaming 
spells may accompany the onset. Sometimes, however, though very 
rarely, the disease develops suddenly in perfectly healthy children 
without any febrile or other disturbance, or it may develop insidiously 
without disturbance enough to attract attention. From the second 




FlG. 394. — Case of Right Hemiplegia At- 
tempting to Walk. 



FlG. 395. 



Attitude in Attempted Walkinj 
Spastic Paraplegia. 



year, for the first six or seven years of life, the liability very gradually 
diminishes ; the number of cases, however, rises slightly at the time of 
the second dentition. In this respect it offers a sharp contrast to in- 
fantile spinal paralysis. 

When the paralysis is noticed, it is found to be most often hemiple- 
gic in distribution. Monoplegia is rare. The face is paralyzed in a 
moderate proportion of all cases, and the arm is always affected more 
severely than the leg and recovers more slowly. The facial paralysis 
ordinarily is not complete and does not affect the muscles that close 
the eyes. It disappears first of all the paralyses, and often recovery is 
complete. Strabismus is very common. The paralyzed side is power- 
less, but sensation is generally unimpaired ; coldness and vascular slug- 
gishness are present in some of the severer cases. The reflexes of the 



SPASTIC AND OTHER PARALYSES. 447 

affected side are much increased from the first — a sign which is of the 
greatest assistance in diagnosis. As in the hemiplegia of adults, rigid- 
ity of the affected muscles comes on in about seventy-five per cent of 
all cases at a varying time after the onset of the paralysis. The rigid- 
ity, when present, is increased by any attempt to use the limb ; it is 
excited by passive manipulation and it disappears during sleep and 
usually under an anaesthetic. Post-hemiplegic movements follow in a 
certain proportion of cases. Hemianopsia may be present. 

Aphasia accompanies probably a certain proportion of cases of cere- 
bral paralysis, but it is often transitory. It is always motor aphasia 
and may accompany either right or left hemiplegia. 

Mental enfeeblement, varying from complete idiocy to simple back- 
wardness, develops in a large proportion of all cases. In the 26 cases 
in the Children's Hospital series ' only 6 had what was classed as aver- 
age intelligence, and 1 of these was aphasic and 1 stuttered very badly. 
Of the rest, 7 were idiotic, 8 feeble-minded, and 4 very backward. 
Sachs found idiocy present in 35 per cent of all diplegias and in 60 per 
cent of paraplegias, while it occurred in but 13 per cent of hemiplegias. 
Such children as escape mental deterioration in childhood often develop 
psychoses later in life. 

Epileptic attacks appear in the paralyzed limbs and thence become 
generalized in one-quarter to one-half of all cases reported. Ordinarily 
they come on in two or three years after the paralysis, but they may 
be delayed, and ten or even thirty years may elapse sometimes; on the 
other hand, they may begin within a few weeks of the onset. 

The mind may, however, remain perfectly clear in spite of a severe 
hemiplegia, and no sign of mental deterioration may be present in the 
early or the late history of the disease. 2 

To the later history of the affection belong the atrophy and contrac- 
tions of the limbs. In hemiplegia the affected side rarely recovers en- 
tirely, and often the growth of the bones is retarded. The muscular 
atrophy, as a rule, is not so great as in infantile spinal paralysis, but in 
certain cases the muscles waste very much. In severe cases there is 
marked arrest of growth in the bones. In the Children's Hospital 
series one case showed a shortening of two inches in the arm after the 
paralysis had lasted seventeen years, and three other cases of four, 
seven, and eight years' standing showed a shortening of one inch. 
This points to some trophic lesion. 

The permanent contractions that come on are most noticeable in 
the arm, and as a rule are of one type in the arm and \&g. In the 
former the arm is held close to the side, the elbow is flexed strongly 

1 Lovett : Boston Med and Surg. Journal, cxviii., 641. 

2 Spiller: "Spastic Spinal Paralysis." Philadelphia Med. Journal, June 21st, 
1902. 



448 



ORTHOPEDIC SURGERY. 



and firmly, the hand is flexed, and the fingers are drawn into the palm, 
usually embracing the thumb. The humerus is rotated inward, and 
outward rotation is resisted by muscular contraction. Supination and 
extension of the fingers are resisted. These contractions are very firm 
and resisting. The leg in bad cases is adducted and flexed at the hip, 
the hamstring muscles of the knee have contracted, and flexion of the 
knee has resulted, and the foot is in a position of talipes equino-varus 
or simple equinus. In other cases only the finer movements of the 
hand may be lost, and the leg movements may be impaired only enough 
to cause a bad limp. 

Post-Pamlytic Disorders of Movement. — In certain cases of hemi- 
plegia, single and double, a disturbance of motion occurs at a later 
stage, which is spoken of under many different names, such as atheto- 
sis and chorea spastica ; while what is called " congenital chorea " in 
many cases is the same affection. 

Spastic Condition of the Muscles. — At times the tonic spasm of the 
muscles becomes the most prominent feature of the case, and there is 
a persistent stiffness and constant spasm of the muscles of the legs and 




Ftg. 396.— Atrophy of the Hand in a Case of Hemiplegia of Several Years' Duration. (Knapp.) 



sometimes of the arms ; the legs are straight and rigid, and the feet are 
extended, and when an attempt is made to walk the child stands on 
tiptoe, and often the spasm of the adductor muscles is so great that the 
legs are crossed. The walk is almost characteristic — a clinging gait, 
in which the feet are scraped along the floor with much effort and 
straining at every step, if indeed the spasm is not so great that walking 
at all is out of the question. 

In general this affection is the result of a cerebral lesion and a de- 
scending degeneration of the lateral columns of the spinal cord. 

This grade of affection in the majority of cases represents the result 



SPASTIC AND OTHER PARALYSES. 



449 



of a larger brain lesion than takes place in hemiplegia. For this rea- 
son, these children are for the most part feeble-minded or idiotic — as 
one might reasonably expect as the result of so extensive a brain lesion 
occurring at so early an age. 

However, one not uncommonly sees children of more than average 
intelligence affected with spastic paraplegia, so that the existence of 
spastic paralysis is by no means evi- 
dence of mental inferiority. 

Often these children have strabis- 
mus, a stupid, idiotic face, the saliva 
drips from the mouth, and the teeth de- 
cay very earl)-. In the milder cases the 
difficulty in walking lies in the fact that 





fig. 



397. — Attitude Assumed in Sitting by 
Feeble-Minded Child. 



FlG. 398. — Spastic Paraplegia in an 
Adult. 



any effort to use the limbs increases the muscular spasm and tends to 
throw the leg into the position of extreme adduction, with extension 
of the foot and generally slight flexion of the knees with talipes 
equinus. It is often impossible to demonstrate the increased tendon 
reflexes either at the knee or at the ankle on account of the great 
stiffness of the legs, because the muscles are continually at their 
maximum of contraction. The electrical reaction in these and in the 
hemiplegia cases is unchanged. 

In certain cases the spasm is so great that the patient is unable to 



45° ORTHOPEDIC SURGERY. 

stand alone. When supported, the thighs are adducted very closely 
and the toes pointed and crossed. 

The mental disability may be manifested in the milder cases by an 
excessive irritability and a disposition to do mischief and perhaps to 
destroy playthings wantonly. Furious outbursts of temper are not 
uncommon. 

It seems as if spastic paralysis of the legs were occasionally a sequel 
of simple hemiplegia coming on after some years. 

Inco-ordination or Idiocy. — This condition may be the accompani- 
ment of cerebral palsy or it may be the result of other causes. 

The classification of Sachs is as follows : 
j (ci) congenital. 
(&) developmental. 

j after traumatism. 

2. Acquired idiocy <{ after convulsions. 

after infectious diseases. 

3. Myxedematous idiocy. 

The only excuse for its introduction here is the very close outward 
resemblance that these conditions present on superficial examination to 
the spastic cases already considered; but definite paralysis and spastic 
rigidity of the muscles are absent, and idiocy obscures everything. If 
patients are seen seated, the stupid cross-eyed look, the drooping head, 



Hereditary idiocy j 




Fig. 399. — Severe Infantile Spastic Paralysis. 

and the drooling are exactly what is seen in the severe mental enfee- 
blement of spastic paralysis or hemiplegia. But put the child on his 
feet and the difference is at once evident. Either his muscles are so 
lax that he will be unable to bear his weight at all, or he will stand 
holding his parent's hands with his feet wide apart, his knees bent, and 



SPASTIC AND OTHER PARALYSES. 451 

his trunk leaning forward. The whole body sways to and fro with an 
oscillating movement, and the sense of equilibrium seems almost want- 
ing; if he is let alone, he walks in a staggering, uncertain way, with 
many falls. From this the condition grades off to a disability so great 
that the child cannot even sit up ; when it is propped up the head lops 
on to one shoulder, the vertebral column fails to support the trunk and 
bends to a marked degree, and every muscle seems limp and useless. 
There is no suspicion of muscular rigidity or localized paralysis. 

Sensory disturbances are not uncommon, and often a pin can be 
thrust through the skin without pain. The reflexes are sometimes nor- 
mal and sometimes increased, while the legs are generally flabby and 
cool, and the hands and feet often undeveloped. Every grade of the 
condition is seen from that described above to complete helplessness. 

Etiology of Spastic Paralysis. — The etiology of prenatal cases of 
cerebral palsy is obscure. Such cases may occur in neurotic and epi- 
leptic families. Traumatism to the mother during her pregnancy, 
severe illness of the mother, severe fright, and hereditary syphilis are 
among the causes. The etiology of cases dating from birth is better 
formulated. Asphyxia at birth, prolonged labors, and instrumental de- 
liveries are frequent causes. 

In cerebral paralysis acquired after birth there are certain well-for- 
mulated causes. 1 Acute infectious diseases play their part, cases hav- 
ing occurred after measles, scarlatina, typhoid fever, smallpox, tonsil- 
litis, pneumonia, pertussis, cerebrospinal meningitis, gastro-enteritis, 
mumps, diphtheria, dysentery, typhus fever, and syphilis. Fright and 
trauma are two other accepted causes. 2 

In a large number of cases the disease seems to affect perfectly 
healthy children without any assignable cause. The indigestion attacks, 
the fever, and the convulsions attending the onset cannot fairly be as- 
signed as causes. The disease is about evenly divided between the 
sexes. 

Pathology. — The pathological condition is much the same in hemi- 
plegia, diplegia, and paraplegia. These conditions in general are due to 
embolism or hemorrhage, and the resulting retardation of growth of the 
affected portion of the brain, together with the secondary changes in 
the spinal cord. Autopsies made later in the disease show pathological 
changes which are more extensive and less definite in their character. 
Wasting and sclerosis of a greater or less part of the brain and the con- 

1 Phila. Med. News. 1S87, ii. — Parvin : American Journ. Med. Sci . 1S75. — 
Sinkler: Med. News. 1S85. vol. i.— McNutt: Am. Jour, of Obst . 18S5.— Parrot : 
" Clinique des Nouveau-nes," Paris. 1877. 

- Obstet. Trans.. London, vol. xxvi. ; Boston Med. and Surg. Journal. June 
28th, 1S88.— Osier: Phila. Med. News. July 14th. 1888.— Abercrombie : St. Earth. 
Hosp. Rep., xvi., p. 35, and Brit. Med. Journ.. June iSth. 1887. 



452 



ORTHOPEDIC SURGERY 



dition known as porencephalus are what one finds in these later cases. 
These seem to be the late results of the destructive change mentioned 
above, which have occurred in a growing brain and have retarded its 
growth and have produced an extensive scar formation in the place of 
cerebral tissue. Porencephalus occurs as a loss of substance in the 
form of cavities or cysts. 

The pathology of the condition ' is a lesion of the motor tract of the 
brain with consequent atrophy and retarded development of the affected 
portion, and descending degeneration of the pyramidal tracts and lateral 




Fig. 400 —Distorted Brain in Case of Infantile Spastic Paralysis. 



columns of the cord. From the extensive atrophy found in young chil- 
dren at autopsy, it seems that unquestionably sometimes the disease 
originates in defective development of the nervous centres, especially 
the pyramidal tracts, rather than in an acute cerebral hemorrhage or 
embolism. 

The theory that the condition was due to a poliencephalitis similar 

1 E. H. Bradford : Am. Journ. of Orth. Surgery, vol. i., p. 375. 



SPASTIC AND OTHER PARALYSES. 45 3 

to poliomyelitis has not received confirmation nor the support of mod- 
ern neurologists. 

To enter upon a discussion of the pathological condition in the cases 
of inco-ordination spoken of above would be to introduce the very ex- 
tensive subject of the pathology of idiocy. 1 

Diagnosis. — Spastic paraplegia is characterized by tonic contraction 
of the muscles which yields to steady resistance, except in the advanced 
stages where fibrous changes have taken place. The galvanic reaction 
is normal. At times the muscular rigidity is so excessive that the ex- 
aggerated knee-jerk and ankle clonus cannot be obtained. In estimat- 
ing the child's mental condition, very little weight can be attached to 
the parents' account of the patient's capacity. 

The differentiation of cerebral paralysis and infantile spinal paraly- 
sis has been dealt with. 

Obstetrical paralysis might be mistaken for a cerebral lesion, but a 
careful examination would determine the paralysis to be limited to the 
distribution of some especial nerve or group of nerves. ' It occurs in 
the distribution of the facial nerve after the use of the forceps, but it 
occurs as a rule in the shoulder in consequence of the stretching of the 
nerve trunks in the manual extraction of the child's body. 

Cerebral tumors may cause the symptoms of hemiplegia, and a diag- 
nosis of this condition from the lesions generally causing paralysis 
would ordinarily be impossible. Tumors of the pons or cerebellum 
would cause symptoms of bilateral rigidity (spastic paraplegia) if they 
compressed the motor tracts. 

Pseudo-hypertrophic paralysis, the pseudo-paralysis of rickets, syphi- 
lis of the spinal cord, and hereditary spastic paralysis are possible 
sources of an error of diagnosis in obscure cases. Certain cases of 
chorea prove on investigation to have their origin in a slight cerebral 
paralysis. The same may be said of epilepsy. 

Prognosis. — The prognosis in these cases should be most guarded, 
and is dependent upon the extent of the central lesion, not always easily 
recognized. When epilepsy or idiocy is present little benefit can be 
expected from surgical treatment. The spastic muscular condition is 
to be regarded as a difficulty in addition to the epilepsy or idiocy 
which especially needs treatment. When no mental impairment 
is present much benefit can be expected from suitable surgical treat- 
ment. 

In formulating the prognosis it is to be remembered that epilepsy 
develops in about half of the cases. 

1 Osier: Med. News, Phila., August nth, 1888, p. 143.— Landouzy and Sire- 
dey: Rev. de Med., 1S85.— Jendrassik and Marie: Arch, fur Phys., 1885.— Gow- 
ers and Handford : Brit. Med. Journal, 1887, i., 1098.— Seibert : Arch, of Pe- 
diatrics, March, 1888, 168. 



454 



ORTHOPEDIC SURGERY. 



Treatment. — In spastic paralysis it is at times possible to accomplish 
much by muscular training and exercise. The muscles which are most 
strongly contracted are the thigh adductors and the calf muscles. 
Such a patient should be given exercises calculated to develop the ab- 
ductor muscles and the dorsal flexors of the foot, which by increased 
power will in a measure counterbalance the muscles which are too pow- 
erful. The patient should lie on the back on a hard table, and should 
separate the legs as far as possible at first without being touched, and 

then against slight resistance. 
The legs in the extended posi- 
tion should be rotated outward, 
while the heels are kept to- 
gether. In walking the patient 
should be cautioned to go very 
slowly, to lift each foot well off 
of the ground, and to turn out 
the toes with much care. In 
connection with massage and 
rubbing, this method of treat- 
ment is capable of accomplishing 
a decided change in the method 
of walking, and, while the walk 
may be stiff and unsteady, it has 
lost the characteristic scraping 
and dragging of the spastic gait. 
Such patients walk with much 
less fatigue than before and feel 
much more steady upon their 
feet. 

The disappearance of the 
aphasia is aided by systematic 
training and it always proves 
more tractable than in the adult. 
Apparatus is suited to the 
treatment of the milder deformities only. Talipes equino-varus of a 
mild degree may be temporarily corrected by a proper appliance (Chap- 
ter XXI., 21). The muscles furnish sufficient support to the affected 
limbs, but, owing to the increased reflex excitability and to imperfect 
motor impulses, the muscles are in a state of spasm and of useless- 
ness from the distorted position. In general the deformities are to 
be treated as in infantile paralysis. The deformity, however, returns 
immediately on removal of the appliance, so that, apart from the tem- 
porary rectification, apparatus is of little advantage in cerebral par- 
alysis. Retentive apparatus, however, is of use in retaining the limbs 




Fig. 401. — Spastic Paralysis before Operation. 



SPASTIC AND OTHER PARALYSES. 



455 



in proper position after operation (Chapter XXI., 25). Post-hemi- 
plegic movements are at times relieved by placing the member at rest 
for some weeks or months under restraint. 

Operative Treatment. — Tenotomy, Myotomy ', Fasciotomy. — Clini- 
cal evidence has proved that tenotomy, especially of the tendo Achillis, 
in this class is of great benefit in suitable cases, not only in improved 
walking, but sometimes in improvement of the general condition and 
diminution of the general irritability, from the benefit of increased ac- 




FlG. 402.— Spastic Paralysis after Operation. 

tivity. The orthopedic surgeon will meet a certain number of cases of 
this class with pronounced equinus deformity of one or both feet. Lo- 
comotion is difficult for the reason that it is impossible for the patient 
to bear the weight upon the whole sole of the foot. This increased 
difficulty is sometimes sufficient to deter the patient from efforts at lo- 
comotion and always adds to the unsteadiness of gait. If tenotomy of 



45 6 ORTHOPEDIC SURGERY. 

the tendo Achillis is done, the contraction ceases, and though the 
strength of the muscle is not lost in a number of cases which have 
been watched by the writers for several years, there is little tendency 
to a reappearance of the equinus deformity. 1 

In instances of this sort a practical cure may be gained by tenotomy. 
This treatment is especially suited to those cases in which there is lit- 
tle or no mental disturbance. 

Division of the hamstring tendons by open incision should be done 
when they are suffiicently contracted to prevent the full extension of 
the knee. This operation is preferable to subcutaneous tenotomy be- 
cause it offers a better chance to divide contracted tissues other than 
tendons. 

In the severer cases with adductor spasm division of the adductor 
tendons is also of benefit, as the adductor spasm often causes the knees 
to knock together in walking and is a serious obstacle in progression, 
and even the weakening of the muscles spasmodically contracted by 
removal of a portion of the muscular bellies is often of use. Gibney 2 
has removed the tensor vaginae femoris with benefit to correct the 
inversion of the limb not infrequently met. In many instances, how- 
ever, if the intermuscular septa and the intermuscular fasciae are 
thoroughly divided in the spasmodically contracted muscular area, the 
remaining portion of the muscle can be overstretched. 

After-Treatment. — After the operation the limb is to be fixed 
in an overcorrected position by means of plaster-of-Paris bandages or 
retentive appliances for several weeks. This is to be followed by 
muscle training, gradually increasing exercises, with limbs held by 
ambulatory retention appliance (similar, as a rule, to what are to be 
used in infantile paralysis) until the proper muscular balance has been 
established, when appliances are to be discarded. 

It is to be remembered that the affection is not strictly a paralysis, 
but a disability from imperfect muscular co-ordination, increased by 
muscular contraction in certain muscles. The treatment consists in 
not only restoring the muscular balance, but in muscle training to re- 
establish the proper muscular co-ordination. Care is necessary during 
the process of muscle training with apparatus not to overstretch the 
divided tendons, as, for example, after division of the tendo Achillis, as 
locomotion with stiffened knees, necessary in the earlier stages of after- 
treatment of a contracted limb, brings unusual strain upon the tendo 
Achillis. It is advisable, therefore, in tenotomy of this tendon (where 
hamstring contraction exists), to perform plastic tenotomy. This is 
done by dividing half of the tendon at different levels and on different 

1 O. Vulpius : "Die Sehneniiberpflanzung," etc., Leipsic, 1902, p. 197 (with 
bibliography). 

-American Journ. of Orth. Surgery, vol. ii., No. 1. 



SPASTIC AND OTHER PARALYSES. 



457 



sides, and by stretching the tendon, elongating it without leaving a gap 
entirely across. 

Tendon transferrence has been recommended in this affection, 
especially of the hamstrings forward, to reinforce the lengthened ex- 
tensor curis by a procedure similar to what is employed in poliomyelitis. 
This would avoid the need of muscle training, with, however, a loss of 
the muscular balance which is always desirable. The procedure should 
be reserved for the more severe cases. 

Tendon transferrence, however, is of great advantage in the spastic 
contraction of the forearm. 

Arm and Hand. — The pronator radii teres may be converted into a 
supinator, 1 and the carpal flexors may be converted into carpal exten- 
sors. 2 In the first operation an incision, two or three inches long, is 
made in the middle of the front of the forearm. The upper and corner 
borders of the pronator are cleared and the tendon with its periosteal 
attachment is freed from the radius. The tendon is then passed through 
the interosseus membrane close to the 
radius and the tendon reinserted on 
the outer side of the radius, if possible 
at the site of its former insertion ; if 
not, at a new roughened place on the 
radius. 

In the other operation 2 the flexor 
carpi ulnaris is divided just above the 
annular ligament and inserted into the 
tendon of the extensor ulnaris, and 
the flexor carpi radialis divided at the 
same level and attached to the radial 
extensor. 

Operations upon the Brain. — 
It is natural that exploratory trephin- 
ing should be attempted in cerebral 
paralysis when the lesion can be well 
localized. Little benefit, however, has 
as yet followed this procedure in 

spastic paralysis, for the reason that the degenerative changes following 
the congenital defect are such as are not relieved by operative inter- 
ference. It is possible, if the operation could be performed at an early 
stage shortly after birth, that benefit might result. 

There are certain motor disturbances affecting children which come 
under the notice of the orthopedic surgeon so frequently that a brief 

1 A. H. Tubby: Brit. Med. Journ., September 7th, 1901. 

- Robert Jones: Tubby and Jones, "Surgery of Paralyses," London, 1903, p. 
225. 





Fig. 403.— Transplantation of the Pro- 
nator Radii Teres in Spastic Paralysis 
of the Arm. 



45§ ORTHOPEDIC SURGERY. 

mention of their characteristics deserves a place here. These affec- 
tions are: 

I. Pseudo-hypertrophic muscular paralysis. Progressive muscular 
atrophy. 

II. Hereditary locomotor ataxia. 

i. PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS. 

Definition. — Pseudo-hypertrophic muscular paralysis is an affection 
of the muscular system characterized by a diminution or loss of the 
functional energy of certain muscles and an abnormal increase in their 
size, which, together with diminution in the size of other muscles, is 
pathognomonic. The affection is also known as muscular pseudo-hy- 
pertrophy, lipomatous muscular atrophy, diffuse muscular lipomatosis, 
myopachynsis lipomatosa (Uhde) ; Paralysie myoscierosique, paralysie 
musculaire pseudo-hypertrophique. Modern classification places the 
affection among the progressive muscular atrophies. 

Etiology. — The etiology of the affection is not known. The disease 
develops usually during childhood, but in exceptional instances its ap- 
pearance is delayed until the age of eighteen or twenty years. It 
affects males more commonly than females in about the proportion of 
four or five males to one female. The disease is more apt to occur in 
family groups than in isolated cases, and the hereditary element is 
marked. 

Pathology. — The pathological condition consists in the overgrowth 
of the connective tissue in the muscles and the wasting of the muscular 
substance proper, while a deposit of fat takes place to a greater or less 
extent. No constant or characteristic pathological condition is found 
in the spinal cord, although various changes have been described, and 
the condition is at present still regarded as a primary affection. 

Symptoms. — The first symptoms to attract attention to the child's 
condition are muscular feebleness and peculiarity of gait. These gener- 
ally precede any noticeable enlargement of the muscles. Such children 
tire very easily in walking and they have especial difficulty in going up 
and down stairs. They fall often and in rising from the ground they 
adopt a procedure which is one of the most characteristic features of 
the disease. Inasmuch as on account of muscular weakness they can- 
not straighten the back or extend the knees without assistance, they 
rise from the ground in the manner shown in Figs. 406, 407, using the 
muscles of the arms to accomplish what the leg and back muscles 
cannot do. 

These children tend to walk with legs apart, and at times an awk- 
ward gait and a tendency to fall are for a long period the only symp- 
toms of the affection. 



SPASTIC AND OTHER PARALYSES. 



459 



Such patients learn to walk late and depend much in their progress 
upon the assistance afforded by the furniture, upon which they lean 
heavily. In kneeling on the hands and knees at times there may be 
noticed a characteristic saddle-shaped depression of the back, which is 
due to the weakness of the erector spinae muscles. This is not an early 
accompaniment of the disease, but is a characteristic of the late stage 
when much lordosis is also present 
in standing. 

In walking these children throw 
the centre of gravity of the body 
well over each leg in turn as it sup- 
ports the body-weight. In this way 
they save muscular effort. The 
result is a waddle more or less 





Fig. 404.— Kyphosis in Pseudo-hypertro- 
phic Paralysis. 



FIG. 405. — Case of Pseudo-hypertro- 
phic Muscular Paralysis. 



marked. They may stand with marked lordosis of the lumbar spine, 
chiefly clue to a weakness of the lumbar muscles. The lordosis disap- 
pears when the patient sits down and a bowing backward of the whole 
vertebral column takes its place. 

Mental enfeeblement is associated with the disease in many cases. 
The enlargement of the muscles is usually most marked in the calves 
of the legs. On this account the parents generally feel no anxiety 
because the child walks late or feebly, inasmuch as the development of 
the legs seems so remarkably good. 



460 



ORTHOPEDIC SURGERY. 




Fig. 406. — Series of Photographs Showing Method of Getting 
up from the Ground in Pseudo-hypertrophic Muscular 
Paralysis. (Curschmann.) 



The affected mus- 
cles are hard and re- 
sistant to the touch, 
but at times the sen- 
sation in handling 
.them is like that of a 
fatty tumor. 

Atrophy of some 
of the muscles of the 
upper extremity is apt 
to be present. The 
scapular muscles, the 
serrati, the latissimus 
dorsi, and the pecto- 
ralis major are often 
wasted. 

Talipes equinus 
and flexion of the 
knees and hips may 
occur from muscular 
contraction. Lateral 
curvature of the spine 
may follow, and at 
other times a perma- 
nent flexion of the 
spine occurs from 
weakness of the erec- 
tor spinae muscles, and 
the child sits bowed 
forward. But these 
deformities mark only 
the late stage of the 
affection, which is 
more often character- 
ized by a helplessness 
more or less complete. 

Neither the re- 
flexes nor the elec- 
trical reactions are 
modified in any degree 
until the muscles have 
reached a marked 
stage of atrophy. 
Then they are dimin- 



SPASTIC AND OTHER PARALYSES. 



461 



ished in proportion to 
the muscular wasting, 
and finally they are 
lost. The reaction of 
degeneration is not 
present. Very often 
the skin over the af- 
fected limb is mottled 
and subject to vascu- 
lar changes, indicat- 
ing some vasomotor 
disturbance. 

Diagnosis. — In 
well-defined cases the 
affection in its later 
stages is not likely to 
be mistaken for any- 
thing else. The pe- 
culiar gait with the 
feet wide apart and a 
reckless disregard of 
falls, the characteris- 
tic method of rising 
from the floor, the 
age of the patient, and 
the progressive char- 
acter of the disease, all 
suggest this affection. 
If examination shows 
enlargement of the 
calf muscles and nor- 
mal or diminished re- 
flexes, the diagnosis 
may be considered as 
established. Yet of 
even greater diagnos- 
tic importance than 
the enlargement of 
the calf muscles is 
the combination of en- 
largement of the in- 
fraspinatus and wast- 
ing of the latissimus 
dorsi and pectoralis 




Fig. 407.— Series of Photographs Showing Method of Getting- 
up from the Ground in Pseudo-hypertrophic Muscular 
Paralysis. (Curschmann.) 



462 ORTHOPEDIC SURGERY. 

major muscles — a state of affairs to which great diagnostic importance 
is to be attached. 

The gait in early hypertrophic paralysis, and that in idiocy, spastic 
paralysis, in the paralysis of rickets and Pott's disease, and in simple 
weakness have very much in common. 

Prognosis. — The prognosis is as unfavorable as possible. Recovery 
is all but unknown, 1 and arrest of the disease is rare.' 2 

The course of the disease is essentially chronic. The earliest stage 
is made manifest by muscular feebleness, and passes on to a stage in 
which hypertrophy of the muscles becomes evident. This stage is pro- 
gressive and at the end of it the pseudo-hypertrophy reaches its maxi- 
mum and the disease becomes stationary and remains so for two or 
three or perhaps several years. Then comes a time of increasing fee- 
bleness and extension of the paralysis. The muscles waste and the 
power of movement is lost in the legs and arms. In this deplorable 
condition the patient may live on until death comes from increasing 
exhaustion or some intercurrent disease. 

Treatment is practically without benefit, and there is no reason to 
believe that drugs have any effect in retarding its progress. Electric- 
ity, massage, and gymnastics are sometimes of benefit in connection 
with other treatment. 

Tenotomy is of use as soon as the heels are drawn up. Often walk- 
ing may become impossible, chiefly on that account, and division of the 
tendo Achillis on both sides may restore for a time the power of walk- 
ing; also tenotomy of the hamstring tendons at the knee may be indi- 
cated in severe cases. 

PROGRESSIVE MUSCULAR ATROPHY. 

Progressive muscular atrophy is an affection characterized by a 
wasting of the voluntary muscles, and a consequent diminution in their 
power, which pursues a chronic course and attacks successively indi- 
vidual muscles and groups of muscles. 

Etiology. — In muscular atrophy as it occurs in children, the only 
cause assignable is a congenital tendency, often inherited. But at 
times isolated cases are met, and in adults other causes are to be taken 
into account. 

Males are more often affected than females, and the time of onset 
of the disease is most variable ; it may begin as early in life as at the age 
of three years or as late as sixty, but its development in advanced life 
is rare. 

1 Duchenne : Arch. gen. de Med., 1868, i., pp. 5 and 6. 

' 2 Donkin : " Note on a Case of Pseudo-hypertrophic Paralysis, Recovery." 
Brit. Med Journal. April 15th, 1S82. 



SPASTIC AND OTHER PARALYSES. 463 

Progressive muscular atrophy has, since the days of Aran and Du- 
chenne, been subdivided into different types. 

1. In the Aran-Duchenne type the atrophy begins oftenest in the 
small muscles of the hand, spreads to the forearm and perhaps the 
shoulders and back. It may begin in the muscles of the thighs. The 
atrophied muscles show fibrillary contractions, and the reaction of de- 
generation is present. 

The affection has a pathology and is of spinal origin. The changes 
found are a sclerotic and pigmentary atrophy of the ganglion cells of 
the anterior cornua, an inflammatory condition of the neuroglia, and 
cellular proliferation. The anterior nerve roots are affected secondarily. 

2. The hereditary form is of the same general type as the preceding. 
It is very unusual and may occur in more than one member of a family. 

3. The peroneal form or leg type of progressive muscular atrophy 
affects in most cases the lower extremities. The extensor muscles of 
the toes are first affected, then the small muscles of the feet, and 
finally the entire leg. Talipes equinus or equino-varus is a common 
result. The development of double club-foot with progressive wast- 
ing" of the lower extremities is very suggestive of this type of the af- 
fection. It may affect the upper extremities first and then the lower. 

Sensory changes are generally present. The reflexes in the lower 
extremities may be diminished or lost if the disease is sufficiently ad- 
vanced. The electrical reactions, as a rule, are altered both quantita- 
tively and qualitatively. Cases of club-foot occurring in this type may 
be successfully operated on. 1 

The changes in the muscles consist in atrophy of the fibres, a loss 
of transverse striation, and a proliferation of the nuclei. Degenera- 
tions of the nerves are present, but changes of importance in the spinal 
cord have not been established. 

The two remaining types along with pseudo-hypertrophic paralysis 
are to be classed as primary myopathies or primary muscular dystro- 
phies, in that they are not associated with demonstrable lesions in the 
spinal cord. 

4. Erb's type. The juvenile form of progressive muscular atrophy 
is very rare and is characterized by progressive wasting of certain 
groups of muscles. These are the muscles of the shoulder girdle, the 
upper arm, the pelvic girdle, the thigh, and the back. The forearm 
and leg muscles remain, for a long time at least, intact. There are no 
fibrillary contractions, no reaction of degeneration, and no sensory dis- 
turbances. 

5. The Landouzy-Dejerinetype or the facio-scapulo-humeral variety 
occurs at times in children. The muscles of the face are first affected 
and the atrophy spreads to the shoulder and arm muscles. In excep- 

1 Sachs : Loc. cit., p. 413. 



.464 



ORTHOPEDIC SURGERY. 



tional cases this type may begin in the arms or legs. The reaction of 
degeneration and fibrillary twitching are never present. 

Treatment. — The medical treatment of all these affections is hope- 
less. When muscular contractions occur tendons should be cut and 
deformities rectified. Rest to the atrophied muscles, massage, and 
electricity are useful. 

HEREDITARY ATAXIA. 

Hereditary ataxia deserves mention as a serious motor disorder 
which is sometimes met in children. It is dependent upon a family 
predisposition, but is not often directly inherited, but more commonly 
appears in several members of one generation. Hence the name of 
family ataxia. It is also known as Friedreich's disease. Other names 
are hereditary ataxic paraplegia and degenerative ataxia. The cases 
are rare. 

Etiology. — Aside from the influence of a congenital tendency the 
cause of the disease is as yet unknown. 1 The disease develops most 
often early in life. The sexes seem equally liable to the affection. 

Pathology. — In examining sections of the cord in these cases, a de- 
generation of the lateral columns, with a more intense and plainly 
marked sclerosis of the posterior columns, is found. This is similar to 
the lesion of locomotor ataxia. 

Symptoms. — The symptoms resemble very closely those of locomo- 
tor ataxia, except that the lightning pains of the early stage and crises 




Fig. 408.— Deformity of the Feet in a Case of Friedreich's Disease. Hyperextension of the 
toes and club-foot. (Marie.) 

are not so marked as in the latter affection. Hereditary ataxia, more- 
over, involves the upper extremities more severely and earlier in the 
course of the affection. 

The patient notices a feeling of weakness and uncertainty in walk- 
ing, and soon it becomes apparent to others that the motions of the 
legs are not properly co-ordinated. The feet are placed wide apart in 
standing, and in walking the gait is practically that of locomotor ataxia. 

lowers: Vol. i., p. 380.— Shattuck : Bost. Med. and Surg. Journal, vol. 
.cxviii., 7, p. 168.— Smith : Boston Med. and Surg. Journ., October 15th, 1885. 



SPASTIC AND OTHER PARALYSES. 465 

The movements of the hands become irregular and inco-ordinate, and a 
jerky irregularity develops in the movements of the head and neck, so 
much so that it may assume the aspect of an irregular tremor. Speech 
may also be impaired. 

The knee-jerk disappears, but the plantar reflex remains. Sensa- 
tion is affected in varying degrees in different cases, and trophic 
disturbances of the skin are not present. As a rule the sphincter mus- 
cles are not affected. Nystagmus is often present ; the Argyll-Robert- 
son pupil is absent. 

Deformities are apt to come on in the later stages of the disease. 
Lateral curvature may be present ; talipes equinus or equino-varus and 
permanent flexion of the knee are likely to occur. 

Diagnosis. — In a clearly marked case the walk is characteristic and 
resembles that of ordinary locomotor ataxia. The deep reflexes are 
diminished or absent and there is a certain amount of disturbance of 
sensation; the electrical reactions are normal. Isolated cases occur 
rarely, and a history of some such affection in other members of the 
same family aids very much in the diagnosis. 

Prognosis — The disease is essentially progressive, and the progno- 
sis is bad in proportion to the rapidity of progress. Death usually 
occurs from intercurrent affections, but sometimes the disease lasts for 
thirty years or more and does not seem to have shortened life. It is 
not likely to cause death inside of ten or twelve years at the least, and 
nothing can be expected from treatment. 

Treatment. — The treatment should be similar to that in common 
use in locomotor ataxia. The general hygiene of the patient should be 
most carefully regulated, and skilful massage sometimes accomplishes 
much in keeping up the nutrition of the muscles and thus diminishing 
the patient's disability. Electricity in the same way is of use, but it 
is distinctly second in importance to proper massage. Deformities 
should be corrected by tenotomy, etc., as they occur. 

Among similar affections are the cerebellar type of hereditary ataxia 
described by Marie, differing chiefly in having exaggerated reflexes and 
ocular symptoms in addition to those described above. 

OBSTETRICAL PARALYSIS. 

Obstetrical paralysis of the shoulder is an affection which is fairly 
common and often results in a disabled arm. It occurs most often 
after difficult labors when traction is made upon the head in head pres- 
entations, or upon the trunk when the head is delivered last. It may 
occur, however, after normal labors. 1 

The injury appears to be due to injury to the two upper roots of the 

1 Boston Med. and Surg. Journal, 1892. 
30 



466 ORTHOPEDIC SURGERY. 

brachial plexus. It has been found experimentally that the two upper 
roots give way first when traction is made, becoming very tense when 
the shoulder is pulled down, while the three lower roots remain lax 
under the same conditions. 1 The paralysis is of Erb's type and the 
nerves involved are the circumflex, suprascapular, musculo-cutaneous, 
and musculo-spiral. 

The condition is made manifest immediately after birth by an inabil- 
ity to use one arm ; it hangs powerless at the side, with the palm turned 
backward, and often the fingers are flexed tightly. If the arm is lifted 
from the side it falls lifelessly back into place, and although movement 
of the fingers is generally present, it is impossible to use the arm to any 
extent on account of the paralysis of the shoulder muscles. 

The prognosis in the severer cases is not good as to recovery. 

The treatment should consist in the use of a sling or supporting 
bandage at first to prevent stretching of the joint capsule and muscles. 
Later massage and electricity are likely to be of use in lighter cases. 
The muscles should not be allowed to acquire a permanent contraction, 
but should be kept lax by daily manipulations of the joint. External 
rotation and supination are the most difficult motions to preserve. 

In cases with contraction, myotomy of the pectoralis major muscle 
followed by retention of the arm in a position to prevent contraction of 
the scar, is of use. 

When the paralysis affects only certain muscles, as is not infre- 
quently the case, operative measures, referred to in the chapter on 
" Spastic Deformities," viz., muscle transference, will be of assistance. 
Portions of the trapezius can be transferred to the deltoid, and other 
muscular transference can be performed in the forearm if any strong 
muscles remain. 

If the biceps is paralyzed and no triceps can be utilized, the arm can 
be made more useful by a procedure suggested by Jones, of Liverpool, 
viz., a flap plastic operation in the bend of the elbow, the skin and re- 
sulting scar tissue serving to hold the arm in a slightly flexed position, 
which is more useful than a straight one. Arthrodesis can be per- 
formed for the same purpose at the elbow. 

1 J. S. Stone : Boston Med. and Surg. Journ., 1899. 



CHAPTER XVI. 

FUNCTIONAL AFFECTIONS OF THE JOINTS. 

Definition.— Etiology.— Occurrence. — Symptoms. — Spine.— Hip.— Knee.— Ankle. 
—Diagnosis. — Prognosis. — Treatment. 

DEFINITION. 

Functional disorders of this class are also termed hysterical and 
neuromimetic. 

The affections of this class most often involve the spine, hip, knee, 
and ankle, although the other joints can hardly be considered exempt. 

These disorders are probably dependent upon a disturbed nervous 
condition, perhaps due to a disordered blood supply, brought about by 
nervous exhaustion from overgrowth, from disease, nerve strain, or 
from trauma. They are here termed functional, because there is no 
evidence, clinical or pathological, of organic disease. Ordinarily these 
disorders are seen in persons of an excitable, emotional temperament, 
but exceptionally the most aggravated type of functional affections may 
be seen in persons of calm and composed demeanor manifesting no ex- 
aggeration in statement or manner. 

ETIOLOGY AND OCCURRENCE. 

A study of the etiology of this class is disappointing. As a predis- 
posing influence, an emotional temperament, which enters largely into 
the exaggerated statement of all subjective symptoms, must be consid- 
ered in all cases. The influence of home training and discipline in the 
development of this temperament is important, as well as is heredity. 
Persons broken down in health by suffering or chronic disease become 
naturally in time incapable of bearing pain, and the statement of such 
patients is exaggerated and the endurance lessened. 

Trauma is a frequent exciting cause. In certain cases the pain 
caused by a synovitis, for instance, seems to be perpetuated after its 
legitimate cause has disappeared. This is due to the patient's abnor- 
mal sensitiveness and self -concentration. Such sensations are to be 
classed as "habit pains." 

Again, slight sources of peripheral irritation, too slight to be an 
inconvenience to normal persons, may be a cause of severe symptoms 
in neurasthenics. Among such causes may be mentioned a short leg 

467 



468 ORTHOPEDIC SURGERY, 

or a weakened foot of slight degree, some degree of thickening of the 
synovial fringes in the knee, etc. 

This condition of hypersensitiveness is sometimes to be seen in 
young girls about the time of puberty, and in elderly women at the time 
of the menopause, rarely in young children. Women in young and 
middle adult life are the most frequent sufferers.. How far sexual irri- 
tation enters into these cases as a causative influence cannot be said 
with certainty, but in some cases it appears to be one of the disturbing 
factors which make up the disease. The statement cannot be too 
strongly made that, although these affections are seen mostly in young 
women at or after puberty, it must not be overlooked that they occa- 
sionally occur in young children, in boys, and also in men. Why a dis- 
turbance of the nervous centres should result in the manifestation of a 
group of symptoms so closely resembling those of serious joint disease 
is but one of the many unexplained phases of this disorder. The same 
may be said of the direction of these symptoms to any particular joint; 
except that traumatism is in many cases the cause which determines 
the concentration of the attention upon some one joint. 

SYMPTOMS. 

These affections may begin gradually or they may be seen following 
accident. Again they may be the outcome of a protracted convales- 
cence from some joint injury. The symptoms presented are usually 
much exaggerated and out of proportion to the local signs. There is 
usually a condition of hyperesthesia, especially of the skin, which 
manifests itself most clearly when any manipulation of the affected 
part is attempted. Although this is a very important factor in the de- 
termination of this class of affections, the absence of this hyperesthesia 
must not be taken as sufficient evidence to exclude the disease. An- 
other characteristic feature of these disorders is the fact that the 
objective signs vary from time to time. The stigmata of hysteria 
accompany many of these cases and when present are of great diagnostic 
importance. 

Organic and functional disease are frequently associated. A young 
woman with some joint affection of a mild character will sometimes so 
exaggerate and emphasize her symptoms that the case may appear to 
be of the most acute sort, but careful examination will perhaps show 
that the disease is convalescent and that the real condition is very favor- 
able. This can be detected only by a careful examination showing 
that the muscular stiffness varies much with the attention of the pa- 
tient and that much pain is attributed to the slightest manipulation 
which can easily be performed without suffering or muscular spasm 
when the attention of the patient is diverted, while the muscular rigid- 



FUNCTIONAL AFFECTIONS OF THE JOINTS. 469 

ity of chronic joint disease is a constant and not a variable resistance 
to passive manipulation. 

Atrophy may be considerable, but it is not more than can be ac- 
counted for by disuse. 

Distortions of the affected limbs have nothing characteristic about 
them, except that they may or may not follow the malpositions of the 
limb which occur in real joint disease. The hysterical knee-joint is 
often flexed, and the hip may be flexed and perhaps adducted or ab- 
ducted. 

In short, the symptoms of functional joint disease have one distinc- 
tive characteristic, they are chiefly subjective, and objective signs of 
structural trouble are absent or not prominent. A familiarity with the 
objective signs of disease of the various joints is of course necessary in 
making the diagnosis of functional troubles, and the foregoing chapters 
have dealt with those objective signs. 

Symptoms often associated with functional disorders are ovarian 
tenderness and pain, baso-occipital headache, a feeling of suffocation as 
if a lump were lodged in the throat, and symptoms of this class. 

The association of uterine disorders is common, and also another 
frequent accompaniment is found in the presence of errors of refraction 
in the eyes. 

The surface temperature may be increased, local sweating may oc- 
cur, and neurologists describe some swelling as an accompaniment of 
certain cases of functional disorder of the joints. 

The correction of all sources of peripheral irritation is of course a 
matter of much importance. 

Spine. 

The condition in this location is also described under the names of 
irritable spine, hysterical spine, spinal irritation, functional affection of 
the spine, weakness of the spine, neuromimesis, etc. 1 The affection may 
occur spontaneously or most often as the result of some trauma, either 
mild or severe. It appears as a sensitive and painful condition of the 
spine, manifested by sensitiveness most often over the spinous processes 
of the vertebrae, pain in motion and manipulation ; and in most of the 
cases is associated with a certain amount of general neurasthenia. 

Pain and tenderness are frequently found at the base of the neck, 
between the shoulders, in the lower dorsal region, or at the end of the 
spine. This pain is usually subacute, it is aggravated by fatigue, and 
it may be accompanied by much hyperesthesia, which is usually local- 
ized in a comparatively small area where there is a complaint of a burn- 
ing sensation, while no curvature or projection can be seen on inspec- 

^riedberg: Schmidt's Jahrb., 1897.— Brims' Beitr., xi., 1894.— Willard and 
Spiller: " Concussion of the Spinal Cord." N. Y. Med. Jour., March 6th, 1897. 



47° ORTHOPEDIC SURGERY. 

tion of the back. In the extreme cases, patients are unable to bear any 
weight upon the spine in sitting or standing, and they present the 
symptoms that suggest a hyperesthesia of the ligaments or of the fas- 
ciae of the back muscles. Ordinarily the patients are able to go about 
freely, but suffer great pain, especially when their attention is turned 
to the subject of themselves. In a few instances of the severest sort 
the back is held stiffly, and any conscious attempt at bending is avoided 
by the patient ; but unconsciously, when the patient's attention is di- 
rected in another way, the back will be seen to move with comparative 
freedom. 

A gait which is very similar to that of Pott's disease may be pres- 
ent, and also rigidity of the back in rising or stooping. As in that 
affection continued standing and walking may cause pain, the patient is 
very sensitive to any jar and may be relieved from discomfort in the 
recumbent position. 

A careful examination of the patient usually shows that the symp- 
toms of stiffness are more from an apprehension of possible pain of 
movement than from the unconscious muscular spasm seen in the acute 
stages of early Pott's disease. Pain on movement, moreover, is usually 
much greater than is seen in early Pott's disease. 

Some deviation from the normal attitude in standing is seen in most 
cases. 1 This may be a slight lateral deviation of the spine due to a 
short leg. It may be a rounded back from lack of muscular support, 
or it may be a position of lordosis and leaning back in an effort to 
balance. Such patients generally are poorly developed muscularly. 
Whatever defects exist should be corrected. 

Certain cases of backache of this type result from flat-foot or con- 
tracted foot. An examination of the feet should always be made. 

Sprains of the vertebral column occur at times after falls. Stiffness 
and pain may reach a considerable degree and render the diagnosis 
from Pott's disease impossible for a time. In the cervical region wry- 
neck may be present from muscular spasm. The pain may be very 
severe. This condition of sprain may persist for months, and in neu- 
rasthenic persons may merge into the so-called hysterical spine. 

Hip. 

The symptoms which may present themselves under these condi- 
tions at the hip-joint may resemble hip disease in many particulars. 
There is often complaint of a severe pain in the limb, and any attempt 
to move the hip elicits expression of pain. There may be an absence 
of atrophy, and the pain is more likely to be localized at the hip than at 
the knee, which is the reverse of what happens in true hip disease. 

Covert: "The Neurasthenic Spine." Am. Medicine, November 30th, 1901 ; 
N. Y. Med. Journal, May 30th, 1903. 



FUNCTIONAL AFFECTIONS OF THE JOINTS. 47 1 



Unconscious movements at the hip-joint may be made more freely 
than in the painful stages of hip disease. In some instances marked 
fixation at the hip-joint may constantly be present, but usually the 
stiffness in examination of the hip is great, but unconscious movements 
at the hip as in stooping are freer. The stiffness is more the stiffness 
of apprehension than the limited mo- 
tion of early disease of the joint. The 
affection in children is not common, 
but by no means exceptional. The de- 
formity may be marked and persistent, 
recurring quickly after reduction. 

■ Knee. 

Functional disease of the knee- 
joints often simulates either chronic 
synovitis or ostitis. Pain and tender- 
ness may be present, creaking is noted 
as an occasional symptom in func- 
tional affections, and at times there 
seems to be present an increase of 
surface temperature. More commonly 
the surface temperature of the af- 
fected side is reduced. The knee may 
be flexed, but during sleep that posi- 
tion may be involuntarily abandoned 
or the leg can be easily straightened, 
offering but little resistance. Con- 
traction of the knee is often absent. 
A moderate degree of muscular atro- 
phy is present, especially if, as is usu- 
ally the case, the knee has heen tightly 
bandaged for some time. 

In rare instances some swelling 
of the periarticular tissues around 
the knee is observed in this class of cases 
and does not involve the joint proper. 

Nowhere does the diagnosis present greater difficulty than at the 
knee, where traumatism may loosen the semilunar cartilages to a slight 
degree or do some similar injury. The diagnosis of functional disease 
can be made only after the careful exclusion of all organic pathological 
conditions in both knee and foot. As our knowlege of abnormal con- 
ditions in the knee-joint becomes more exact fewer cases are classed as 
functional. 




FIG. 409.— Attitude in Walking in a Case 
of Hysterical Affection of the Joints 
of the Leg in a Girl of Thirteen. 

The swelling is transitory 



472 ORTHOPEDIC SURGERY. 

Ankle. 

A functional disturbance in the ankle is not infrequent. It is most 
commonly met as a result of sprains which have been treated for too 
long a time by rest and fixation. A condition of muscular weakness, 
enfeebled circulation, and apprehension at slight pain ensues, and no 
attempt at the proper means of securing recovery is made, for the rea- 
son that the first attempt to use the disabled joint is painful and pain 
is regarded as a symptom indicative of inflammation. 

In functional disease of the ankle an attitude similar to talipes varus 
or of flat-foot may be seen. The distorted attitude in both the knee 
and the ankle may be so constantly assumed as to cause a contraction 
of the hamstrings or tendo Achillis. 

At the ankle most cases of functional affection are either the out- 
come of trauma or are associated with some abnormality of the foot. 

The functional affections of the other joints present no points 
worthy of especial mention. 

DIAGNOSIS. 

The symptoms are often those of organic joint disease, but the 
groups of objective physical signs are deficient and inconsistent with 
one another. The objective signs vary and are not so severe as the 
symptoms would lead one to expect. Pain is the prominent feature, 
and muscular rigidity and similar symptoms are of varying severity, 
according to the concentration of the patient's attention. The pres- 
ence of superficial hyperesthesia and of signs characteristic of hysteria 
with an emotional temperament are facts which should excite attention. 

In examining patients in whom a functional affection is suspected, 
much information can be gained by watching the movements of the 
patient in getting out of bed, moving in bed, etc. The limbs or back 
should be bared, and the unaided movements watched. Those suffer- 
ing from organic disease of the hip or spine show a constant stiffness 
or attempt to guard or protect the affected limb, which is not displayed 
to so marked a degree in purely functional affections. 

The diagnosis to be of value must in practically all cases be made 
by a process of exclusion. Again it must be remembered that func- 
tional and organic disease may exist in the same joint, that is, legiti- 
mate symptoms may be so exaggerated as to constitute a functional 
affection. 

X-ray examinations are of assistance, as they show the absence of 
organic change in the bone structures which would be present in tuber- 
culous disease of a prolonged or acute course. 



FUNCTIONAL AFFECTIONS OF THE JOINTS. 473 

PROGNOSIS. 

If left to itself, a true functional affection of the spine or joints may 
improve gradually without special treatment, or it may remain un- 
changed until the joint function becomes really impaired by the con- 
tinued inaction. In some cases a sudden and profound mental impres- 
sion may prove stronger than the idea of local disease and a cure is 
effected. It is this that the surgeon strives to accomplish in certain 
cases, it is this that may be brought about by faith cure or charlatanry, 
and rational treatment of a similar sort can likewise win excellent re- 
sults if properly carried out. 

The age of the patient and the duration of the affection are impor- 
tant in determining the outlook. The older the patient and the longer 
the course of the disease the less favorable is the prognosis. 

The existence of some peripheral source of irritation renders the 
immediate prognosis perhaps more favorable. 

TREATMENT. 

In few disorders is a routine treatment of less use than in functional 
affections of the joints or spine. Especially important, from the out- 
set to the end of the treatment, is an established diagnosis, on which 
the surgeon can rely. To attempt to follow out a treatment which 
shall be suitable to either functional or organic disease is fatal to a suc- 
cessful issue. Temporizing on the part of the physician at once makes 
successful treatment almost impossible. A definite plan of treatment 
must be formulated and adhered to. 

The disorder usually manifests itself as a disability of a limb, the 
object of treatment being to overcome the disability. Various meth- 
ods will be needed to effect this. 

It is first necessary that the patient be brought into as nearly nor- 
mal a general condition as possible. The improvement of the local 
condition is then to be considered and estimated, and finally the patient 
is to be trained to regain the use of the disabled limb or spine. In 
cases in which the spine is involved, rest to the back must be secured 
by recumbency for part of the day. Elaboration of treatment is desir- 
able in many cases and a rigid adherence to a careful and continuous 
routine of exercises, feeding, and medication must be insisted upon. 
This class of cases cannot be successfully treated unless due attention 
is given to regulating and improving diet and general condition, and 
correcting sleeplessness. 

For the treatment of the local condition, the physician has to decide 
between the necessity of correcting any existing distortion or local im- 
proper conditions of circulation or muscular weakness of the limb or 



474 ORTHOPEDIC SURGERY. 

back, and the clanger of increasing the expectant attention of the pa- 
tient by too great attention to the local condition. It is for this reason 
that counter-irritation and the cautery are to be avoided. It is essen- 
tial that the local condition should not be made light of by the surgeon, 
and the reality of the symptoms must be accepted and the disability 
recognized. A probable hypothesis explaining the condition must be 
assumed, and treatment based upon this should be carefully and con- 
sistently carried out. Any statement that the affection is a trivial 
nervous disorder or that it can be overcome by exercise of the will is 
in most cases an error. 

An important part of local treatment is the improvement of the cir- 
culation in the part affected, and strengthening of the surrounding 
muscles. This can be done by massage, local hot-air baths, electricity, 
and gymnastics. 

In general the beneficial effect of the local measures adopted must 
be insisted on, and by a graduated amount of enforced exercise pro- 
gressively increased, the patient may be surprised into finding herself 
daily doing more without feeling more pain. Sometimes it may be only 
practicable to make the patient take two steps a day, but the advance 
to three and four steps is an important gain. It may be repeated that 
without a certainty on the physician's part that he is dealing with a 
functional affection, and without a rigid adherence to his formulated 
plan of treatment, success is not often to be obtained. 

Great benefit can be obtained by graduated exercises in this class 
of cases. Another useful way of accomplishing this result is by means 
of mechanical passive and active exercises according to the method 
introduced by Zander. 

Appliances as a rule should be avoided, but in some cases they are 
temporarily needed to enable the patient to go about more freely when 
there is marked muscular weakness. They should be discarded as 
soon as is practicable. In the spine the tempered steel uprights (Chap- 
ter XXL, 22) spoken of in connection with round shoulders are of use 
temporarily in aiding in the maintenance of the upright position. 

In functional affections of the hip, knee, and ankle it is sometimes 
necessary to employ crutches in order to give locomotion and exercise. 
Crutches should be used sparingly, and only temporarily, inasmuch 
as there is danger of the patient becoming habituated to them. 

When contractions and malposition of the limbs are present, these 
should be corrected either by operation or by mechanical means. Op- 
erative measures are usually simple, as under an anaesthetic the limb 
can be pulled readily into normal position, while only in severe cases is 
tenotomy of the resisting muscles needed. Appliances will probably 
be required to retain the limb in the corrected position. 

Light cases of functional affection of the hip will be best treated at 



FUNCTIONAL AFFECTIONS OF THE JOINTS. 475 

first by the use of crutches and the elevated shoe to the well foot, aided 
by gymnastic exercises for the limb of such a character as the patient 
can endure. The elevated shoe should be lowered and removed gradu- 
ally, and in the same way crutches should be shortened and replaced 
by a cane, and finally all support discarded by gradual stages. The 
use of a hip splint will not often be found advantageous on account of 
its weight. Traction by weight and pulley is rarely needed, but is 
sometimes advisable. 

Much judgment is required to determine what cases of functional 
affection of the hip, knee, and ankle joints are to be treated by rest, by 
protection of the limb, or by use. 

Rest in bed is to be avoided unless the patient is in a marked neu- 
rasthenic condition needing quiet, but confinement to bed is generally 
unavoidable during the correction of deformity. 

Whatever the methods of treatment to be instituted, it is absolutely 
essential that the physician should have complete control of the man- 
agement of the case without interference of friends or relations. Often 
it is therefore necessary to take the patient away from home for the 
time being. In many cases the home influence is a most important 
factor in inducing and keeping up this condition. 

It is of importance for the physician to obtain the patient's co-oper- 
ation in the treatment prescribed. It is a mistake to belittle the symp- 
toms or to treat them as imaginary. They are not only real to the 
patient, but in fact are probably the result of some unrecognizable cen- 
tral vasomotor disturbance causing functional disability, and not of the 
patient's fancy. The disability is usually increased by the patient's 
apprehension or self-will. These are not overcome by contradicting the 
patient's statements. As the local symptoms of hyperemia, anaemia, 
congestion, atrophy, and muscular weakness are diminished by rest, 
support, careful exercise, application of heat or cold, hot air, vibratory 
massage, manipulation, or whatever measure may be employed, the use 
of the limb should be gradually increased with each day's task prescribed. 
The gradual gain, even if slight, brings encouragement to the patient. 

Cases vary in difficulty and often tax the physician's efforts to the ut- 
most in meeting the varying symptoms, but in many instances such efforts 
are essential as necessary to save the patient from hopeless invalidism. 

In cases in which functional symptoms are superadded to an organic 
lesion, much skill and judgment are required in treatment. 

In all these varieties of functional affections, the principle of treat- 
ment is the same — temporarily to protect the affected part from strain 
and painful use, to improve the circulation and increase the muscular 
strength, and as the condition improves to train the patient to the 
gradual resumption of the normal use of the limb. A combination of 
muscular training with mind cure constitutes the treatment. 



CHAPTER XVII. 
UNILATERAL ATROPHY AND HYPERTROPHY. 

Cases of unilateral difference in the growth of the body are of prac- 
tical interest. 

Hunt, 1 of Philadelphia, in 1879, made observations which led him to 
state that bilateral symmetry as to the length of the lower limbs was 
exceptional. Since then several observers have corroborated the views 
of Hunt. Dr. Cox 2 measured the lower limbs in fifty-four healthy per- 
sons, and in only six were the limbs of the same length. There was no 
uniformity with regard to which side was the longer. The variation in 
length was from one-eighth to seven-eighths of an inch. Wight 3 gives 
the measurements of sixty persons, and concludes " that the greater 
number of limbs, comparing the limbs of the same person, show a dif- 
ference in length. About one person in every five has limbs of the 
same length." The difference is usually from one-eighth of an inch to 
an inch. In one case the difference was as great as one and three- 
eighths inches. 

Callender 4 measured forty individuals, and found the limbs of equal 
length in all but two, in whom the variation was slight. He used a 
simple tape. All the persons measured happened to be Englishmen. 
Roberts 5 and Dwight f ' have attempted to settle the question by obser- 
vation on the bones of skeletons. Roberts found asymmetry the rule 
in femora and tibiae in eight skeletons. Dwight reported measurements 
in eleven skeletons; in five the femora- were equal; in one case the 
difference was three-quarters of an inch. Tibiae were equal in only 
two cases. In some cases the longer femora and tibiae were on the 
same side, and in some cases on different sides. 

Dr. J. Garson, 7 of London, published the results of the measure- 
ments of seventy skeletons. The lower limbs were equal, he says, in 
only ten per cent. 

'Am. Journal Med. Sciences, January, 1879. 
' 2 Am. Journal Med. Sciences, April, 1875. 

3 Archives Clin. Surg., vol. i., No. 8, February, 1877. 

4 St. Bartholomew's Hospital Reports, vol. xiv., 1878, p. 187. 

5 Philadelphia Med. Times, August 3d, 1878. 

6 Mass. Med. Soc. Communications, 1878, p. 175. 

''Journal of Anat. and Phys., vol. xiii., p. 502, 1879. Nature, January 26th, 
1884. 

476 



UNILATERAL ATROPHY AND HYPERTROPHY. 477 



Morton * has made many measurements and found that among 513 
boys 292 presented inequality in the length of the lower limbs varying 
from one-eighth of an inch to one inch and five-eighths. In 241 there 
was no appreciable difference in length. In none of these cases had 
there been previous fracture or any bone or joint disease which might 
have accounted for the defect. Three of the boys, including those that 
exhibited the greatest shortening, were aware of the fact that one limb 
was deficient in length. Burrell 2 
reported three cases of marked 
unilateral atrophy only noticed 
when the children began to walk, 
when it became manifest by a 
limp. 

Broca 3 relates the case of a boy 
of eleven who appeared "as if the 
two halves of the body were differ- 
ent-sized persons joined together." 

Paget 4 found that there is often 
a difference of volume as marked 
as is the difference in length, and 
it is often difficult to say which 
of the two unequal limbs is the 
better or the more appropriate to 
the other parts of the body. In 
Hartwig's studies of the upper ex- 
tremity the bones of the right arm 
were found to be the longest, cor- 
responding with Hyrtl's results. 
Poncet 5 reported a case of alter- 
nate inequality, the right arm 
and the left leg being better de- 
veloped. 

The conclusions reached by all have been nearly identical, namely, 
that throughout the long bones of both extremities there exists often a 
certain amount of asymmetry in regard to length. 

The very important theoretical and practical bearing of this is easily 
seen. The relation that short limbs may bear to cases of lateral curva- 
ture G has been discussed. 




Fig. 410.— Case of Multiple Plexiform Fibro- 
ma. Causing Hypertrophy and much 
Lengthening of Left Leg-. (H L. Burrell.) 



1 "Asymmetry of the Lower Limbs." etc. Phila. Med. Times, July 10th, 1886. 
-Boston Med. and Surg. Journal, vol. cvi.. p. 462. 
3 Canstatt*s Jahresbericht, 1859, vol. iv.. p. 6. 

4 Am. Journal Med. Sciences, January. 1886. 

5 Lyon Medical. January 29th, 1888. 

* Revue de Chirurgie, April 10th, 1888. 



4/8 ORTHOPEDIC SURGERY. 

The progressive facial hemiatrophy is of interest from an etiological 
standpoint. 

The etiology of these different forms of atrophy or hypertrophy is 
obscure. In the cases of injury to the joints Nicoladoni suggested a 
premature synostosis of the epiphyseal cartilages. The facial hemi- 
atrophy is thought to be a trophic neurosis of certain nerve ganglia or 
nerves — or a simple vascular disturbance of the part has been sug- 
gested as a possible cause. 

It is probable that certain of these cases are the result of a slight 
former hemiplegia, which has manifested itself chiefly in retarding the 
growth of the affected side without any distinct loss of motor power. 

Symptoms and Treatment.— Long-continued slight and oftentimes 
severe backaches, with lumbar and pelvic pain, involving the distribu- 
tion of the sciatic nerve, are often due to asymmetry of the lower 
limbs. Such symptoms are at times at once relieved upon correcting 
the asymmetry by increasing the height of the shoe of the shortened 
limb. A person in previous good health may from some depressing 
physical condition begin to have the above symptoms of pain localized 
as stated, and upon examination unequal limbs will be found in very 
many cases. 

Morton said that United States pension-examining surgeons stated 
that many applications for pension have been made for disabilities de- 
scribed as lumbago, supposed to have been caused by exposure or by 
injuries contracted during the war for the Union. In nearly all such 
cases an examination revealed a previously unrecognized asymmetry, 
and the symptoms were probably induced by this defect in develop- 
ment. 

Symptoms of inequality of the lower limbs may simulate coxalgia. 
In such cases the legs should, of course, be measured. Children com- 
plaining of backache, or so-called growing pains, should be carefully 
examined for any such anatomical defects. 

The medico-legal bearing of the fact of asymmetry has been called 
attention to by Hunt in the paper already referred to. 

Hypertrophy of the limbs may occur either from dilatation of the 
vessels (as in angioma), from disease of the lymphatics, and from con- 
genital anomaly. 1 

1 " Clinical Report Children's Hospital Service." Boston Med. and Surg. 
Journ., cxliv., 14, p. 329. 



CHAPTER XVIII. 
CONGENITAL DISLOCATIONS. 

Congenital dislocation of the hip. — Frequency and occurrence. — Etiology. — Pa- 
thology. — Symptoms. — Diagnosis. — Differential diagnosis. — Prognosis. — 
Treatment. — (Reduction with aid of mechanical force. — Tenotomy, fasciotomy. 
— After-treatment. — Relapses — Osteotomy.— Treatment of older and adult 
cases. — Summary.) — Congenital dislocation of other joints — Knee. — Patella. 
— Congenital absence of the patella.— Ankle— Shoulder. — Elbow. — Wrist. 

Cubitus valgus, cubitus varus. — Spontaneous subluxation of the wrist. 

CONGENITAL DISLOCATION OF THE HIP. 

Congenital dislocation of the hip is neither a common affection 
nor one of very great rarity. Among 6,969 orthopedic patients apply- 
ing at the out-patient department of the Children's Hospital, there 
were 152 cases of congenital dislocation of one or both hips. Chaus- 
sier, in 23,293 infants born at the Maternite, found only 1 case of con- 
genital luxation. But it is probable that it occurs in reality much 
oftener than it is recognized clinically. Parise dissected the hip-joints 
of all children dying while he was interne at the Hopital des Enfants 
trouves, and in 332 he found congenital dislocation of one or both hips 
in 3. 

The distribution of the affection between the sexes and in one or 
both joints can be seen from the following tabulation of collected 
cases : 



Drachmann 

Pravaz 

Kronlein 

N. Y. Orth. Hosp. and Disp. 
Boston Children's Hospital.. 
Prahl 



\ umber. 


Boys. 


Girls. 


Single 
Right. Left. 


Double. 


77 


10 


67 


24 


24 


29 


107 


11 


96 


27 


29 


5i 


90 


M 


76 


S 2 


22 


3i 


-5 


2 


2 3 


5 


10 


5 


24 





-4 


7 


11 


6 


18 


3 


15 












341 40 301 95 96 122 

The affection is much more common in girls than in boys, 301 of 
these 341 cases (88 per cent) having been observed in females. No 
satisfactory explanation has been advanced to account for this prepon- 
derance in girls. 

Etiology. — The etiology of the affection is not known. True con- 
genital dislocation without doubt is an affection of uterine life, congeni- 
tal dislocations having been found in the foetus. It would seem also 

479 



480 



ORTHOPEDIC SURGERY. 



that it is not an arrest of development like harelip, but like congenital 
club-foot rather a perversion of it, a malposition of bones with the re- 
sulting structural changes of the soft parts. Violence at birth alone, is 
not considered the cause of true congenital dislocation. The theory 
that the deformity is due to intra-uterine pressure at a period of foetal 
development is held' by many. 1 This theory, however, does not explain 
the fact that the affection is much more frequent among girls than 
among boys. The lack of complete development in the acetabulum 











Fig. 411. — Lordosis and Prominence of Tro- 
chanters in Congenital Dislocation of the 
Hip. (J. S. Stone.) 



Fig. 412.— Unilateral Dislocation of the 
Hip. (Fiske Prize Fund Essay.) 



described by many writers will be found after thorough examination of 
pathological specimens to be explained by the malposition of the parts 
during a portion of the period of foetal life rather than by a structural 
arrest of development. 

1 A specimen was described by Mr. Jackson Clark in which in uterine life the 
thighs were flexed for so long a period without extension as to cause firm contrac- 
tion of the anterior portion of the capsule. Later extension of the limb, possibly 
from an increase of the amniotic fluid or from any cause, would, in a shallow 
acetabulum, cause dislocation of the hip (Brit. Ortho. Trans., vol. i.). 



CONGENITAL DISLOCATIONS. 



481 



There is, undoubtedly, a tendency to heredity in congenital hip dis- 
location. Dupuytren relates the case of three families in which the 
affection was present in several members, and cases are related by 
Bouvier, 1 Verneuil, Stadfeldt, Caswell, and Volkmann. It has been 
observed in two instances at the clinic of the Children's Hospital. In 
each instance two sisters were similarly affected. 

Pathology. — The changes in the anatomical structures seen in con- 
genital dislocation are found in the capsule, in the muscles, and in the 



a 





Fig. 413.— Prominence of Trochanters in 
Double Congenital Dislocation of the 
Hip. (Fiske Prize Fund Essay.) 



FIG. 414. — Lordosis in 
Dislocation of the 
Fund Essay.) 



Double Congenital 
Hip. (Fiske Prize 



bones. The changes in the capsule are such as would naturally follow 
a prenatal dislocation before the joint structures were formed. Nor- 
mally the capsule passes from the rim of the acetabulum to the neck of 
the femur, the head being placed well in the socket. In congenital dis- 
location, when the head lies out of the socket and above the acetabu- 
lum, the capsule is stretched. Furthermore, the weight of the body, 
as soon as the individual walks, rests not on the head of the femur 

1 Bouvier: " Lee. Clin, sur les Mai. chron. de TApp. locomoteur." 
31 



482 ORTHOPEDIC SURGERY. 

placed under the acetabulum, but falls upon the capsule, which stretches 
like a strap from the acetabulum to the trochanter, and this capsule 
necessarily becomes thickened. As it is stretched across the acetabu- 
lum it becomes adherent at the rim and to a portion of the ilium, so 
that the acetabulum seems obliterated, being covered by thick, strong, 
fibrous tissue, reaching from rim to rim. This portion of the capsule 
is entirely shut off by adhesion from that which surrounds the head, 
save for a small opening at the upper portion of the rim. This open- 
ing may be, and usually is, smaller than the head, and not easily 

stretched, as the tissues lose their elas- 
ticity owing to the fibrous bands which 
form from the use of the capsule as a 
weight-bearing structure. 

The muscles are changed in conse- 
quence of the altered position of the head. 
Some of the muscles are shortened, others 
are lengthened. The muscles which are 
shortened are the adductor group, the 
psoas and iliacus, and the muscles reach- 
ing from the tuberosity of the ischium to 
the leg, i.e., the hamstring muscles. The 
glutaei muscles are not shortened, and the 
group of muscles which pass from the 
pelvis to the greater trochanter, the ob- 
turators, gemelli, etc., are lengthened. 
The capsular and periarticular ligaments 
adapt themselves to the position of the 
deformity, and those which are attached 
to the lesser trochanter are particularly 
strong and firm to prevent the pushing of 
the head upward, when weight falls upon 
: " the leg. It is these tissues which oppose 
any attempt at reduction, and unless they 

FlG. 415. — Hroadening of Perineum J 

in Double Congenital Disioca- are stretched or divided the deformity can- 
tion of the Hip. (Fiske Prize not be cor rected. The alteration in the 

Fund Essav.) . 

bone consists of a flattening or alteration 
of the shape of the head, a twist of the neck, the consequence of mal- 
position of the head, and in the shape of the acetabulum, which is 
sometimes triangular in shape and shallow. 

Three varieties of congenital dislocation, classified according to the 
position of the head, are mentioned, viz., backward, upward, or forward. 
The backward or dorsal is much the most common. 

If the point of suspension is directly over the proper place for the 
acetabulum, the patient's pelvis is hung in a comparatively normal 




CONGENITAL DISLOCATIONS. 



483 



plane, but if much behind it the pelvis is tilted and severe lordosis re- 
sults, the latter being the more common condition. 1 

Symptoms. — The deformity usually attracts no attention until the 
child learns to walk at the age of two or even three years. Then it is 
noticed to stand ordinarily with its back very much arched and to wad- 
dle most markedly when walking is well begun. This waddle is char- 
acteristic and very marked. When the dislocation is only unilateral,, 
the waddle becomes an exaggerated limp ; in stepping on that leg the 
child leans to the affected side, and the leg seems to have grown sud- 
denly shorter; the child recovers itself at once and goes on with this 
sudden giving way whenever the affected leg is stepped upon. In 




Fig. 416. — Congenital Dislocation of the Hip in Full-term Foetus. (Warren Museum.) 



double dislocation, in young children, the prominence of the trochan- 
ters is not marked enough to attract attention ; in older persons, how- 
ever, the prominence of the trochanters and buttocks is most notice- 
able. There is no complaint of pain by children suffering from this 
affection. 

Diagnosis. — The diagnosis rests chiefly on one point, the position 
of the trochanters above Nelaton's line, which is drawn from the ante- 
rior superior spine of the ilium to the tuberosity of • the ischium. In 
small, plump children it is sometimes difficult to determine accurately 
whether the trochanter is on the line or very slightly above it. The 
displacement of the trochanter upward varies from half an inch to one 

1 The pathological condition of congenital dislocation has been recently most 
thoroughly investigated by Dr. E. H. Nichols, of Boston, to whom the writers are 
indebted for information on the subject (Trans. Am. Orth. Assn., 1896). 



4§4 



ORTHOPEDIC SURGERY. 



or two inches, according to the severity of the case, but on careful pal- 
pation the head of the femur can often be felt on deep pressure if the 
limb is rotated, as moving in an abnormal excursion outside of the ace- 
tabulum. 

As the child lies on its back, the perineum is noticed to be unusu- 
ally broad in double dislocation, the legs will perhaps be everted, per- 
haps in normal position, and on manipulating them they will be found 
in young children to be unusually movable, especially in the direction 
of eversion. 

On pulling the leg with gentle force the trochanter will be felt 




Fig. 417.— Congenital Dislocation of the 
Hip in Full-term Foetus. Capsule re- 
moved. (Warren Museum.) 



Fig. 418. — Specimen of Congenital Dislocation of 
Hip. A, Capsule stretched around distorted 
head ; B, portion of contracted capsule ; C, cap- 
sule leading to acetabulum. 



drawn down, if the other hand is placed upon it, and to slip back when 
the leg is released, and a measurement will show that the leg has been 
lengthened temporarily by the traction force. 

The muscles, although not normally developed, are not paralyzed, 
and the children are ordinarily healthy ones. In unilateral dislocation 
the leg of the affected side is slightly smaller than the other. 

In larger children and adults the conformation and outline of the 
hips, are so distinctive that the diagnosis may be made almost at a 
glance ; but in young children palpation or a skiagraphic examination 
is often necessary. 



CONGENITAL DISLOCATIONS. 



485 



Trendelenburg has called attention to an important diagnostic 
symptom. When a normal child stands upon either limb and flexes 
the other at the knee and thigh, the opposite buttock will be seen not 
to drop. In the case of congenital dislocation of the hip, however, the 
opposite buttock will be found to drop to a noticeable degree if the 
patient takes this attitude. This is to be explained by the fact that in 
congenital dislocation of the hip, owing to the fact that the head of the 
femur is not in the socket, the muscles from the great trochanter and 
the pelvis (which serve to keep the pelvis level) when supported on one 
side have no purchase and are therefore inefficient. 

In small children with fat buttocks it is sometimes difficult to find 




FIG. 419. — Congenital Dislocation, Child of Ten. Femur 
sawn and sides reflected, showing dislocated position of 
the femoral head, the capsular pouch, the capsular hy- 
men in front of the acetabulum, the acetabular cavity, 
and capsular constriction at the mouth. (Warren Mu- 
seum.) 




\ < 

FlG. 420. — Congenital Dislo- 
cation of the Hip. Cross 
section of femur and ace- 
tabulum (femur turned 
back), showing capsular 
constriction at mouth of 
acetabulum. Child three 
years old. (Warren Mu- 
seum.) 



with certainty the dislocated head. The diagnosis is aided by remem- 
bering that when the head of the femur is in the acetabulum, rotation 
takes place with the acetabulum as the centre, and the neck as the ra- 
dius of the arc of motion ; when the head is out of the acetabulum, the 
trochanter is the centre of motion, and the looser head describes the 
arc. 

A skiagraphic picture is of great value in diagnosis, and if accurate 
is conclusive. 

Differential Diagnosis. — The following affections may be confounded 



486 



ORTHOPEDIC SURGERY. 



with congenital dislocation of the hip in smaller children : coxa vara, 
distortion following infantile paralysis, separation of the epiphysis, de- 
formity following early arthritis of infancy, traumatic dislocations, and 
the deformities of hip disease. 

In all these affections, with the exception of the first, viz., coxa vara, 
there should be a history of previous injury or illness; and in all, with 
the exception of coxa vara and infantile paralysis, the freedom of motion 
of the femur seen in early congenital dislocation is not found. 

Coxa vara, or the distortion of the neck of the femur, which short- 
ens the limb and raises the trochanter above Nelaton's line, may be 




FlG. 421. — Femur in Congenital Dislocation, Showing Alteration in Angle of Neck. 

confounded with congenital dislocation. The mistake can be avoided if 
the fact is borne in mind that in coxa vara the head is in its normal 
socket, while in congenital dislocation the head is to be felt outside of 
the acetabulum. Coxa vara is only very exceptionally noticed as early 
as three years of age. 

The affection of congenital dislocation is occasionally regarded as a 
disease of the spine, as marked lordosis is always present, and in many 
instances spinal corsets have been applied with the idea that this is the 
chief source of the trouble. 



CONGENITAL DISLOCATIONS. 487 

Prognosis. — The disability caused by this affection in childhood is 
slight. The limp is noticeable, and, in double congenital dislocation, 
may be distressing. As the patient becomes older and the weight 
increases, some annoyance may be caused in adolescence; but this 
ordinarily is not great until middle life or old age. In single disloca- 
tion the defect in adults may be only an inability to engage in active 
occupation, accompanied by occasional attacks of severe muscular 
pain, with muscular cramps. These attacks subside under rest, but 
if the patient becomes heavier or feeble they may necessitate the use 
of crutches and cause severe disability. When the dislocation is on the 
dorsum the disability is greater than when it is anterior or above the 




FlG. 422. — Old Congenital Dislocation of Hip with Alteration of Neck of Femur to Shape of 
Acetabulum. (Warren Museum.) 

acetabulum. Muscular patients suffer less than those with feeble mus- 
cles. In double dislocation the trouble is increased. 

No strong acetabulum develops around the dislocated head, and 
with the body suspended from the femurs by a loose capsular ligament, 
the patient goes through life walking with discomfort and effort at each 
step, always preserving that most characteristic swaying from side to 
side. 

It may be said that in general the tendency of these cases when 
untreated is to remain stationary or to grow somewhat worse. The 
pelvis, although altered in shape, does not appear to be changed in such 
a way as to interfere with childbirth. 



483 



ORTHOPEDIC SURGERY. 



The prognosis in cases which are treated will be considered under 
that head. 

Treatment. — Attempts at reduction without operation have proved 
unsuccessful, although cases by Pravaz, Buckminster Brown, and 
Adams were thoroughly treated by traction for a long period and ap- 
parently benefited at first. The ultimate results were, however, en- 
tirely unsatisfactory, and the method cannot be recommended. 

Operative measures when first attempted without a thorough 





FIG. 423. —Congenital Dislocation, Showing 
Dropping of Pelvis when Patient Stands 
on the Affected Limb. 



IG. 424. — Coxa Vara, Showing Elevation of 
Pelvis when Patient Stands on Affected 
Limb. 



knowledge of the pathological conditions also failed, but through the 
valuable work of Hoffa and Lorenz successful operative methods have 
been developed and a reasonable and increasing percentage of success 
is obtained in suitable cases. 

Mechanical treatment and the treatment by traction continued fcr a 
long period, advocated by Pravaz, Adams, and Buckminster Brown, 
have not given results which were permanently successful. 

The operative methods may be termed : 

1. Reduction by open incision. 

2. Reduction by forcible manipulation. 



CONGENITAL DISLOCA TIONS. 



489 



Reduction by Open Incision. 

To Hoffa belongs the credit of having first presented to the pro- 
fession an operative method of value. This has been modified by 
Lorenz and himself and may be described as follows : 

The patient is to be placed upon the back with the limbs slightly 




J 



Fig. 425. — Double Congenital Dislocation Unreduced. 

abducted and rotated outward. The incision is made in a line drawn 
from in front of the anterior superior spine, obliquely downward and 




FIG. 426.— Line of In- 
cision for Opera- 
tive Reduction. 



FIG. 427.— Second 
Step. 



Fig. 428.— Third 
Step. 



Fig. 429.— Fourth Step. 



backward, crossing the femur a short distance below the top of the tro- 
chanter. The incision should be along the outer edge of the tensor 
vaginas femoris, between this and the anterior border of the glutaeus 



ORTHOPEDIC SURGERY. 




FIG. 430.— Congenital Dislocation Reduced. 



CONGENITAL DISLOCATIONS. 



491 



medius. The incision should pass well below the top of the femur, and 
should cross it slightly above the level of the trochanter minor. The 
tensor vaginas femoris is retracted and the fascia lata divided by a 
straight incision, and, if necessary, by an additional cross incision. The 
glutaeus is also retracted, and beneath the tensor muscle the rectus 
femoris will be found, with a reflected tendon passing outward, to be 
attached to the ilium above the acetabulum. If the muscular tissues 
are well retracted the capsule will be uncovered and can be split. This 







FIG. 431.— Congenital Dislocation. Reduction by incision. Osteotomy of shaft to correct 

twist of neck. 

should be done by an incision in the direction of the original skin incis- 
ion, and should be free enough to expose the whole head and neck as 
far as the trochanteric line, and, if necessary, a cross incision is made. 
An assistant should flex the thigh to a right angle to the trunk, and 
the attachments of the capsule to the neck and the trochanteric line, 
including the lesser trochanter, should be thoroughly freed both on the 
anterior and posterior surface of the neck to such an extent that the 
surgeon can pass his finger completely around the neck. The head can 
then be thrown out, the ligamentum teres having been divided, if pres- 



49 2 ORTHOPEDIC SURGERY. 

ent. The head of the femur can then be pulled aside and a clear view 
of the capsule covering the acetabulum, as well as the acetabulum, can 
be had. If the capsule is constricted above the acetabulum it can be 
cut with a herniotome or stretched with a dilator or enlarged with a 
curette. It is important that the bony edge overhanging the acetabu- 
lum should project sufficiently to furnish a firm socket after the head is 
reduced. It is sometimes difficult, if the tissues are imperfectly divided, 
to find the socket, for' the reason that a portion of the capsule lies flat 
across the socket and is adherent to the edges, the surgeon feeling only 
the upper edge and a mass of connective tissue ; but when this difficulty 
is met it is necessary to enlarge the incision, as it is essential that the 
head be placed well in the socket. It is not infrequently necessary to 




FlG. 432. — Double Congenital Dislocation of the Hip. Reduction on left side by open incision. 
Relapse on right side after attempted manipulative reduction. Capsular constriction at 
mouth of right acetabulum. Death six months after operation. 

deepen the acetabulum by means of a curette or gouge. This is neces- 
sary if the acetabulum is abnormally shallow. 

It is sometimes necessary, if the head of the femur is conical in 
shape, to remove a portion ; but if the cartilage on the acetabulum is 
removed and the head of the femur freed from its cartilage, ankylosis 
is liable to result. It is particularly necessary that the capsule should 
not be folded in attempted reduction in such a way as to prevent the 
free entrance of the head into the acetabulum, and it is especially impor- 
tant that the connection between the acetabulum and the femur at the 
trochanteric line and lesser trochanter should not be so firm as to pre- 
vent the easy reduction of the head into the socket. When it is found 
that the head when reduced into the socket will not remain there if the 
leg is adducted or extended, some remaining fibres of the capsular at- 
tachments on the anterior surface, passing from the ilium to the lesser 



CONGENITAL DISLOCATIONS. 



493 



trochanter and its adjacent parts, will be found to exist. After the 
acetabulum has been deepened sufficiently, the reduction of the disloca- 
tion should be performed. 

After the reduction the redundant capsule can be closed, with a 
wick for drainage, or packed, according to the judgment of the surgeon. 




Fig. 433.— Diagram of Section of Capsule in Normal and in Congenitallj' Dislocated Hit:, 

Drainage is to be regarded as of importance, as the cavity is a deep one 
and may be shut off. Furthermore, in this region the danger of infec- 
tion from urine, in small children, is to be considered. The experience 
at the Boston Children's Hospital has, however, been in favor of clos- 




FlG. 



Fig. 434. 
FIGS. 434 and 435.— Diagram Showing Difficulties in Reduction. 1, In the capsule covering 
the acetabulum ; 2, in the shortened capsule between the acetabular rim and the lesser 
trochanter. 



ing the wound at the time of operation, leaving only a gutta-percha 
tissue wick, to be removed in a short time. When absolute confidence 
can be placed in thorough asepsis, closing the wound in this way at 
the time of operation saves for the patient a long period of wound- 



494 



ORTHOPEDIC SURGERY, 



healing. The limb should be flexed by means of a plaster-of-Paris spica 
reaching from the thorax down to the foot, holding the limb in a 
strongly abducted position. The position of the limb can be gradually 
brought to normal by later application of plaster-of-Paris bandages. 

Reduction by Forcible Manipulation. 

This method, requiring necessarily the employment of an anaesthetic, 
was first attempted by Post, of Boston, without a permanent successful 
result. Paci, at the International Medical Congress in Rome, showed 
several cases successfully treated by a manipulative method of reduc- 
tion under an anaesthetic. This has been elaborated by Lorenz, of 
Vienna, who has extensively demonstrated the details of the method. 




Fig. 43 6. Fig. 437. 

Figs. 436 and 437. —Diagram Showing Pelvi-trochanterie and Pelvic Muscles in Congenital 

Dislocation of Hip. 

The method of manipulative reduction is based on the fact that in 
many instances the head can be placed in the acetabulum after all the ob- 
structions caused by the contracted soft parts are overcome by stretching, 
and that this can be done satisfactorily by using the femur as a lever. 

Complete anaesthesia is necessary. The child's ankle is grasped 
firmly and a strong pull exerted, counter-pull being furnished by an as- 
sistant who presses upon the perineum or, in the more resistant cases, 
pulls upon a folded sheet, one end of which is passed under the peri- 
neum. The limb should be rotated forcibly to both the outer and inner 
side, and then forcibly abducted both with the knee flexed and straight. 

It is essential that the adductor group of muscles should be over- 
stretched or torn, and this can be aided by forcible massaging or by 
striking with the hand the belly of the long adductor. After the limb 
has been brought to a right angle with the axis of the trunk, and in 
some instances twenty degrees beyond, the knee being straight, it 
should be again brought in a line of the axis of the trunk and then 
forced upward with the knee straight, until the thorax is touched by the 



CONGENITAL DISLOCATIONS. 



495 



front of the thigh, thus stretching the hamstring muscles. The child 
should then be turned upon its face and forcible hyperextension used, 
both with the leg abducted and straight. The child is then placed upon 
its back and reduction attempted, the surgeon holding the patient's 
limb just below the knee, which is flexed with one hand, the other hand 
being placed upon the pelvis, the palm pressing on the crest of the 
ilium and the thumb passing behind and beneath the trochanter. The 
thigh is then flexed and abducted, and with the limb in this position the 
operator should press the head of the femur downward with the exer- 




FiG. 43 8 -~ Dissection Showing Tendinous Insertion of the Lower End of the Adductor Magnus 



cise of strong force, to stretch the lower border of the capsule. The 
child is then turned upon its face and hyperextension exerted, both 
with the limb abducted and in a line with the body. 

The child is then placed upon its back and an attempt at reduction 
made. If the tissues have been sufficiently stretched by the above- 



49 6 



ORTHOPEDIC SURGERl 



mentioned manoeuvres, the reduction can be easily made. The surgeon 
holds the patient's limb just below the knee with the hand, abducts the 
limb strongly, flexing it at the knee. The other hand is placed upon 
the pelvis, the palm of the hand resting on the anterior spine, and the 
thumb being placed under the trochanter, while an assistant steadies 
the pelvis by pressing upon the opposite side. The patient's knee is 
pressed downward from the plane of the operating table, while the tro- 
chanter is pressed upward and slightly forward. In successful cases 
the head will be felt to slip into the acetabulum with a sudden move- 
ment characteristic of the reduction of a dislocation. 

It is often necessary to give slight rotary motion to the limb and 
slight manipulation is often necessary. The surgeon can use the head 




FlG. 439.— Manipulative Reduction in Congenital Dislocation of the Hip. Traction and 

reduction. 

of the femur to determine the size and depth of the acetabulum, and 
the firmness with which it is held in the acetabulum is also to be noted. 
In the more resistant cases a padded, wedge-shaped block placed 
behind the trochanter will be of assistance, serving to push the tro- 
chanter and head of the femur forward, while the patient's knee is 
pressed downward. When the head of the femur is well in the acetab- 
ulum it can be felt on careful palpation, lying under the point of inter- 
section of a line following the femoral artery, with a line crossing the 
pelvis at a level with the top of the symphysis pubis. A tightening of 
the hamstrings will usually be observed on reduction of the hip. After 
the reduction has been made, the limb should be carefully brought into 
a straight position, i.e., parallel with the long axis of the trunk. If dislo- 
cation occurs during this manipulation the tissues must be stretched 
still further and the head again placed in the acetabulum. 



CONGENITAL DISLOCA TIONS. 



497 



Reduction with the Aid of Mechanical Force. 

In the younger cases little difficulty will be encountered in stretch- 
ing the shortened muscles by the use of manipulation as described, but 
in older cases much force is necessary, which involves danger of fracture 
of the femur or pelvis, both of which accidents have occurred in manipu- 




'■'^^ 



W: 




FlG. 440.— Manipulative Reduction. Forced abduction stretching the adductors with blows 
upon the adductor attachment. 

lative reduction. A difficulty encountered where manual force is em- 
ployed is in holding the pelvis. This is essential to the accurate em- 
ployment of force, and the accurate employment of force is of the 
greatest importance if much force is to be used. 

It is for this reason that mechanical aids have been advised in the 
reduction of congenitally dislocated hips. One of the most efficient of 
apparatus for the purpose is an appliance devised by Mr. Ralph W. 
Bartlett, of Boston. 1 It consists of a perineal resistance plate, traction 




FlG. 441. — Manipulative Reduction. Forced flexion with leg straight at knee. 

rods, and cylinders, which press on the pelvis at and above the tro- 
chanters. The traction rods are attached to the cylinders, and moving 
about each cylinder is a metal collar controlled by a handle. The collar 
is armed with a plate which can be made td press the trochanter down- 
pour, of Med. Research, new series, vol. v., December, 1903, pp. 440-448. 
3 2 



498 



ORTHOPEDIC SURGERY. 



ward and forward. The cylinder is pivoted upon an eccentric pin, and 
when moved by a wrench can be made to increase the pressure of the 
trochanteric plate. 

The patient is placed in the apparatus with the perineum pressing 
on the perineal plate; the trochanteric cylinders are adjusted to press 



: 



X*7 




FIG. 442.— Manipulative Reduction. Hyperextension. 

upon and above the trochanters. The patient's ankles, protected by 
saddlers' felt and leather, are connected to the windlass at the bottom 
of the traction rods by means of rawhide straps. With the aid of this 




> 




FlG. 443.— Manipulative Reduction. Head of femur pressed into acetabulum by manipulation 
after all contracted tissues are relaxed by overstretching. 

mechanism, traction to any extent can be applied, and in connection 
with it a strong abducting force, with, in addition, a force which will 
press the trochanter and head downward when the limb is strongly 



CONGENITAL DISLOCATIONS. 



499 



abducted. The danger of fracture is diminished, as the replacing force 
is applied when the head is pulled away from the pelvis. 

This appliance has been used at the Boston Children's Hospital for 
the past two years, after careful experiments upon cadavers, and its effi- 
ciency proved in a series of thirty cases, some of these of the more 
resistant type. 

The Bartlett machine is to be regarded as a stretching appliance 
rendering the manipulative reduction easy after the thorough stretch- 
ing. In some instances a reduction takes place by the aid of the appa- 
ratus alone, rotation of the stretched 
limb being sufficient to lift the femoral 
head into the acetabulum. In the 
more difficult cases, however, the child 
is to be removed from the stretching 
apparatus and the ordinary manipula- 
tions applied. 

Tenotomy, Fasciotomy. — The most 
important tissues other than the cap- 
sule which need to be stretched to en- 
able the surgeon to replace a congen- 
itally dislocated femoral head are the 
adductor group of muscles, the ham- 
strings, and the fascia lata, including the 
ilio-femoral band. 

The adductor group of muscles can 
be stretched with comparative ease, with 
the exception of the fibres of the ad- 
ductor magnus, which pass from- the 
tuberosity of the ischium and are col- 
lected into a tendon of considerable 
size, which is inserted in a tubercle 
above the internal condyle of the femur. 
These fibres are not of importance in 
limiting the adduction of the limb and 
are not stretched by forcible abduction. 

They do serve, however, as a check to lengthening the limb, and in re- 
sistant cases offer the strongest resistance to a traction force needed 
to pull the head of the femur down to the level of the acetabulum. 
This resistance can be readily overcome by tenotomy of the tendon at 
the lower end of the adductor magnus. If a small incision is made on 
the inner side of the internal condyle of the femur, this tendon can 
be easily found, a director or hook passed underneath it, and a divi- 
sion of the tendon made without difficulty by a scalpel or scissors. 
It will be found that no other tissues in the adductor group will 




Fig. 444.— Plaster Fixation after Reduc- 
tion of a Congenitaily Dislocated Hip. 
Foot raised to improve locomotion. 



500 



ORTHOPEDIC SURGERY. 



offer serious obstacle to the stretching movements preliminary to 
reduction. 

The ilio-tibial band which offers the strongest resistance to elonga- 
tion of the limb can be readily divided by a tenotome inserted beneath 
the skin a short distance above the external condyle. The band is 
from an inch to two inches in width, and can be easily felt beneath the 
skin on the outer side of the leg when traction is applied to the ankle. 





JJ.B Cj'fJtfS •»»» ieeet.t r .c T.tT>1$, 
t • ftrttttff •» tritttantcrl 

X>D fUtUl *#//*r *fv*. tfh~4i* 




in\tbf'f ey/i'nete- 2?' f tu.tt.' n ^ 

■r »r, UH rf. »^ttt«l,/r.t /k.r. * 
J) arm fi*tlf'*f • » % o-$«r, 
T Jrts.ta.1 Collar- aratxttJL Cyfi 



■>dtr 




Fig. 445.— Details of Bartlett Machine, Showing Effect of Eccentric Movement. 

In double congenital dislocation of the hip where lordosis is well 
developed, the anterior portion of the fascia lata offers an obstacle when 
traction is applied, this force acting rather to increase the lordosis than 
to pull down the femoral head. This obstacle can be overcome by 
dividing the fascia near its attachment to the anterior superior spine. 
If a small incision is made through the skin a short distance below the 
anterior superior spine and the skin is retracted the fascia can be divided 
freely. 

Although the hamstring: muscles offer considerable resistance to 



CONGENITAL DISLOCATIONS. 501 

pulling down the dislocated femoral head, tenotomy of their tendons, 
though easily performed, is rarely necessary, for the reason that the 
resistance of these muscles can be readily eliminated by flexing the 
thigh and knee. After the reduction it is important to stretch these 
muscles that the limb should be placed in a normal position without 
dislocating the head. This can usually be accomplished by forcible 
straightening of the limb with the knee extended after the head has 
been reduced. The above-mentioned procedures need not be considered 
except in the more resistant cases. No other resistant tissues are of 
importance, with the exception of the capsule. 

These measures are usually not needed, as the tissues can be 
stretched without resort to tenotomy in ordinary cases. 

Accidents. — The method of reduction of congenital femoral disloca- 
tion by manipulation is not without danger and requires the exercise of 
considerable judgment. Fracture of the femoral head, fracture of the 




FIG. 446.— Bartlett Machine. Reduction of congenital dislocation of the hip. 

pelvis, death from shock, rupture of the femoral artery, temporary and 
permanent paralyses have all followed the injudicious use of force in 
correcting this deformity. These accidents can be avoided if the method 
is limited to the less severe cases. 

Slight paralyses not infrequently follow manipulative reduction, but 
pass away without treatment in a short time. 

From the experience at the Boston Children's Hospital it would 
appear that the danger of injury in forcible reduction is diminished by 
the employment of a mechanical appliance similar to the Bartlett ma- 
chine. Great care, however, and judgment are necessary in the use of 
this as of all powerful aids. 

After-Treatment. — After the hip has been placed in the acetabu- 
lum, it is necessary that it should be held in the socket until the capsu- 
lar tissues are sufficiently strong to prevent a relapse. 

The child, while still under the anaesthetic, is placed upon a pelvic 
support and a firm plaster bandage applied to the thigh and pelvis, pro- 
tected by stockinet, felt, and cotton. The thigh should be flexed and 
abducted so that it is held at a right angle w T ith the long axis of the 
body and with the inner condyle on the same plane as the symphysis 
pubis or a little lower. In this position the muscles are at a disadvan- 
tage in exerting a dislocating force ; the neck of the femur points for- 



502 



ORTHOPEDIC SURGERY. 



ward and the head is pushed forward. This position renders difficult a 
relapse in the direction of a backward dislocation and favors the cica- 
trization of the posterior capsular tissues. It favors anterior displace- 
ment, however, and the contraction of the tissues which check the 
bringing of the limb to the normal straight position. 

The position should be changed as soon as danger of a relapse in a 
backward direction is past. If it is necessary to retain the limb in the 




Fig. 447. —Six and One-half Years Old. Congenital dislocation of left hip. One year after 
reduction by operative mechanical stretching and manipulation. 

strongly flexed and abducted position for several months, the limb 
should be rotated daily while still in the plaster, to check the contrac- 
tion of the pelvic trochanteric muscles. After the danger of a relapse to 
a posterior dislocation is past, the limb can be fixed in the second posi- 
tion. 

For the second position the limb is brought down to a position of 
abduction of forty-five degrees. In cases with a well-developed socket 
and well-reduced head the limb can be placed in this position imme- 



CONGENITAL DISLOCATIONS. 503 

diately after operation. It is the practice of some surgeons to allow 
the patients to walk about immediately after reduction, placing a high 
block under the flexed foot, in the expectation that the use of the limb 
will favor a deepening of the socket. For this the plaster needs to be 
cut so as to allow motion at the knee and free motion at the well hip. 
It is safer, however, to fix both the hip-joint and the knee of the 
affected side for a few weeks after the forcible reduction, carrying the 




Fig. 448.— Showing Strength of Reduced Hip by the Trendelenburg Test. Motion and gait 

of reduced hip normal. 

plaster well down the limb and around the opposite perineum. After 
the tissues have recovered from the laceration of reduction, the plaster 
can be shortened so as to allow the patient to enjoy more freedom. 
The length of time during which it is necessary that the plaster band- 
age should be worn varies, with each case, from two to six months or 
even a year 

In order to prevent the contraction of the muscles when the limb is 
placed in the plaster-of-Pans spica, it is desirable not only that the 



504 ORTHOPEDIC SURGERY. 

child should walk about as freely as possible after the first few weeks 
following the operation have passed, but that the limb be rotated inside 
the plaster-of -Paris spica by an attendant, who, holding the patient's 
ankle, endeavors to straighten the limb at the knee and gently turns 
the foot inward. After the time has passed when plaster fixation is no 
longer necessary, daily exercise should be given, directed to increasing 
the motion at the hip-joint. It is necessary to stimulate the muscles 
which are not being used, and to stretch by gradual exercise the mus- 
cles which may remain contracted. The patient should be given both 
passive and active exercises. In the passive exercises the manipulator 
should place one hand upon the pelvis with slight pressure above the 
trochanter, and with the other move the femur in the direction of flex- 
ion and adduction, the patient being recumbent. Movement should 
also be made to straighten the limb at the knee and turn the foot in- 
ward, bringing the limb gradually in the direction parallel with the 
other. Similar active exercises can be undertaken and conducted with 
care daily. 

Relapses. — Although it may be claimed that a large number of 
cases of single congenital hip dislocations under ten years of age can be 
reduced (with or without the aid of mechanical force), it must be ad- 
mitted that a considerable number of apparently cured cases relapse. 
The results have been divided by Lorenz into anatomical and functional 
cures, the latter term being applied to the cases in which the femoral 
head is near but not in the socket. But for the sake of accuracy it is 
desirable to avoid classing with successful cases those in which a failure 
in the attempted surgical procedure has resulted, even if the patient's 
condition may have improved. 

While perfect results can be obtained in a considerable percentage 
of cases by forcible manipulative reduction, the causes of relapse need 
consideration. One of the most common is what may be termed im- 
perfect reduction, i.e., a reduction into the acetabulum with the folds 
of the enlarged capsule crowded into the socket in front of the femoral 
head. In some instances an hour-glass contraction of the capsule exists 
in congenital dislocation of the hip, too great and too firm to permit the 
passage in attempts at reduction of the femoral head through the con- 
stricted portion. It has been thought that the use of the limb in walk- 
ing in the after-treatment enables the pressure of the femoral head to 
wear through the folded capsule. Evidence to support this is lacking, 
and, considering the toughness and nature of the folded capsule and 
the large percentage of relapses, it is probable that when this condition 
exists (a condition verified by pathological evidence and where open 
incision has followed attempts at forcible reduction) relapse is inev- 
itable. 

Relapse may follow where the capsular tissue fails to hold with suf- 



CONGENITAL DISLOCATIONS. 



505 



ficient firmness in the acetabulum the reduced head after reduction. 
This takes place when a cotyloid ligament is not developed, and when 




the muscles are not sufficiently strong to keep the femoral head in 
place, or when tissues, contracted in the flexed and strongly abducted 



5°6 



ORTHOPEDIC SURGERY. 



position of after-treatment, prevent the placing of the limb in the 
normal position without causing displacement. 

Care in after-treatment may prevent relapses in many instances of 




£> cS 

a S 

•2 S 

o « 

£ 60 



fe 



this class. Careful examination of the cases during after-treatment by 
manipulation and with the skiagraph, the use of gymnastics, and mas- 



CONGENITAL DISLOCATIONS. 507 

sage will be of advantage in restoring the muscles to their normal con- 
dition. 

Relapses result also from abnormality in the shape of the femoral 
head and in the shape of the acetabulum. It is impossible by manipu- 
lative reduction to place securely a distorted femoral head into an 
equally distorted and smaller acetabulum. Permanent reduction is 
also made difficult by the twist of the femur, which gives an abnormal 
direction to the femoral neck and consequent abnormal muscular rela- 
tion. The importance of the femoral twist in causing relapse after con- 
genital dislocation has been exaggerated. It has been found by the 
investigation of Mikulicz and also by Soutter that a femoral twist may 
exist to a considerable extent without causing noticeable disability. 
When a femoral twist of ninety degrees is present, it is impossible for 



Lotiq a;xi5 necJt. 




Transverse 
xis condijlea. 



FIG. 451. — Twist of Xeck in Congenital!}- Dislocated Femur, Looking from Above Downward. 

the patient to walk normally with the femoral head in the socket. 
Under these circumstances an osteotomy of the femur is necessary. 

Osteotomv. — When osteotomy is necessary it can be performed 
by the use of an osteotome or a chisel, dividing the femur beneath the 
lesser trochanter by a linear osteotomy. If this operation is performed 
shortly after reduction, it will be found that some danger is incurred of 
displacing the reduced head by the use of the mallet and the osteo- 
tome. This danger can be avoided by the division of the femur a short 
distance above the condyle, employing a Gigli saw. This is easily ac- 
complished by passing a large, curved needle around the femur, care 
being taken that the needle should be kept close to the bone on the 
inner side and thus avoid any danger of injuring the artery or nerve. 
No difficulty will be encountered in placing the wire, and, although the 
skin and muscular tissue maybe somewhat injured in dividing the bone, 
the injury is no greater than that met in an ordinary osteotomy. It is 
safer to divide by the saw the greater part of the bone, leaving a por- 
tion to be broken that the remaining portion may serve as a splint to 
steady the fragments. The treatment after correcting the rotation by 
rotating the foot outward is the same as that of an ordinary fracture. 



508 



ORTHOPEDIC SURGERY. 



As a guide to prevent the twisting of the upper fragment, a small steel 
wire can be driven into the trochanter during the operation. Any 
twist of the upper fragment will be readily noticed. 

Prognosis After Treatment. 

The results obtained in the treatment of congenital dislocation of 
the hip show a gratifying increase in the percentage of permanent cures 




Fig. 452.— Untreated Case of Double Congenital Dislocation. Unable to walk without 



as the knowledge of the pathological conditions of the deformity has 
been more thoroughly understood and as technical skill has increased. 

The results obtained at the Children's Hospital in the treatment of 
congenital dislocation of the hip from 1884 to 1903 inclusive will serve 
as a commentary on the progress made in the treatment of the affec- 
tion and will define the prognosis. 

I. From 1 884 to 1896 — 21 cases. Treated by mechanical appliances 
without operation, 7; by incision and curettage (Hoffa's early opera- 



CONGENITAL DISLOCATIONS. 509 

tion), 12; by manipulation under ether (Post), 2. Successful, o; un- 
successful, 21. 

II. From 1896 to 1902 — peases. By open incision, 34: Successful, 
11; unsuccessful, 6; result unknown, 17. By manipulation, 20: Suc- 
cessful, 1; unsuccessful, 7; result unknown, 12. 

III. Cases operated in 1902 — 22 cases. By incision, 2: Successful, 
o; unsuccessful, 2. By manipulation, 20: Successful, 8; unsuccessful, 
2; relapse, 3; anterior transposition, 7. 

IV. £zras- operated in IQOJ—JJ eases. By mechanical stretching 
and manipulation, 24: Successful, 16; unsuccessful, 3; transposition, 




FIG. 453.— Double Congenital Dislocation of Hip. Child aged four. Untreated. 

5. By manipulation, 8 : Successful, 6; unsuccessful, 1; transposition, 1. 
By incision, 1 : Unsuccessful, 1. 

These figures indicate the development of the treatment of the 
affection from the earlier attempts at treatment without operation until 
the recognition of accepted methods of treatment. The results reported 
as obtained in the year 1903 were carefully examined by a committee 
of surgeons six months or a year after operation, and may be regarded 
as representing the permanent condition. 1 

1 "Report of the Orthopedic Staff of the Boston Children's Hospital, Based 
upon Observations in One Hundred and Forty-six Cases." Boston Med. and 
Surg. Jour., vol. cli.. No. 4, p. 85, July 28th, 1904. 



510 ORTHOPEDIC SURGERY. 

It is difficult to determine from statistics the exact percentage of 
success to be expected from the open incision and from manipulative 
reductions. Statistics, however carefully compiled, vary in accuracy 
and in standards of success. An examination of the later statistics 
shows conclusively that the method of reduction by operative manipula- 



FlG. 454.— Same Patient, Age Twenty-eight. Untreated case. Patient able to walk actively 

with little limp. 

tion (the so-called bloodless reduction) may be expected to give perma- 
nent anatomical cures in from ten to twenty per cent of the cases, and 
improved, i.e., functional cures, in at least sixty per cent of the cases. 

The claim that a greater percentage of cures can be obtained by 
open incision carefully performed with the latest improvements in tech- 



CONGENITAL DISLOCATIONS. 



5-i i 



nique is probably justified, although the results of the earlier attempts 
at open incision were not satisfactory. 

The statistics offered by Hoffa of later results from the open incis- 
ion with improved technique are highly satisfactory. 

Treatment of Older Adult Cases. — Baer, of Baltimore, has 
operated with success upon an adult patient of twenty-five years of age 
with double congenital dislocation. The reduction was accomplished 
by means of an open incision with deepening of the acetabulum. The 
second hip was operated upon two years after the first. Although a 
satisfactory result was obtained in this instance, such success cannot be 
anticipated in a majority of instances, and the risk of stiffening the 




Fig. 455. — Plaster-of-Paris Fixation after Manipulative Reduction of Double Dislocation, 
Showing Amount of Ecchymosis. 

joint is considerable. Some benefit is obtained by manipulative treat- 
ment, with or without an anaesthetic, in increasing the arc of motion 
and the usefulness of the limb. As a rule, however, the best treat- 
ment in adult or older cases is by gymnastics, which will strengthen the 
muscles in the lumbar and gluteal regions. 

The use of a stiffened corset holding the hips and the dorsal region 
firmly, either made of stiffened leather or of cloth stiffened with steel, 
will be found of benefit in many of these cases in furnishing support to 
the back. 

Summary. 

Surgeons will vary somewhat in their choice of methods of opera- 
tion, according to their experience and success with the methods of 
reduction by forcible manipulation or by open incision, but these facts 
may be said to be generally accepted : 

As a rule no attempt at reduction is advisable under two years of 
age, as the tissues are not sufficiently developed to prevent relapse. 

In the early cases, from two to five years of age, reduction is easily 
accomplished by forcible manipulation. 



512 ORTHOPEDIC SURGERY. 

In older cases, from five to ten, except in children with weak mus- 
cles, although reduction by forcible manipulation is often not difficult, 
reduction is much easier after stretching by the Bartlett machine, and 
in some cases the reduction is impossible without the aid of the Bart- 
lett machine. 

In cases older than ten, as a rule, reduction by open incision is to be 
preferred ; and in resistant cases under ten, where there is reason to be- 
lieve alteration of the shape of the head and acetabulum or a firm and 
narrow hour-glass contraction of the capsule exist, reduction by open in- 
cision after a thorough stretching of the muscular tissues is advisable. 

In cases of doubt as to which method to employ, the surgeon can 
regard it as a safe rule to follow if reduction is first attempted by 
forcible manipulation, employing open incision if relapse follows. Al- 
though the operation by open incision cannot, if performed with skill, be 
regarded as more dangerous than that of forcible manipulation, as a 
rule it is less acceptable to parents of patients. 

Where the acetabulum is too shallow to hold the reduced head, it 
should be deepened if a lasting reposition is to be expected, but no sur- 
geon should attempt this procedure or the reduction by open incision 
unless assured of complete asepsis in every surgical detail. 

The length of time needed in after-treatment must be determined 
by the condition found after reduction, and must be left to individual 
judgment in each case. 

Double cases are to be regarded as more than twice as difficult as 
single. Attempts at reduction by forcible manipulation should be made 
on both hips at the same time, but if open incision is employed, as a 
rule two separate operations are necessary. 

KNEE. 

Congenital dislocation of the knee is seen with greater frequency 
than that of some of the other joints. 1 It occurs most often in the form 
of hyperextension of the leg on the thigh, which has been considered 
by some writers a displacement rather than a true dislocation forward. 
In some cases the lower epiphysis of the femur is bent forward on the 
shaft. 2 It is in any event a congenital affection of importance when it 
occurs. It is frequently double, and the displacement may be directly 
forward or forward and to one side. The leg forms a right angle with 
the thigh, the apex of the angle being backward, and the condyles of 
the femur can be felt in the popliteal space ; the patella is often small 
and occasionally absent, and lateral mobility may be present. Modifi- 
cations in the shape of the bone, ligaments, and cartilages in the knee- 

1 Drehman : Zeitsch. f. orth. Chir., vii., 22 (98 cases). 
- Delan^lade : Rev. d'Orthopedie, May, 1903. 



CONGENITAL DISLOCATIONS. 



513 



joint, even to the point of ankylosis, have been recorded in some of 
these eases. The deformity may be associated with malformation of 




Fig. 456. — Congenital Dislocation of the Knees Forward in a Young Adult. 

other parts, and the cause can be given no more clearly than that of 
other congenital deformities. 

Forward displacement of the leg at the knee is to be treated by 
manipulation in the direction of correction and the application of a 
solint to the knee to hold the leg in a corrected position. Following 



( 



C^ 



~t 



Fig. 457.— Congenital Dislocation of the Knee. (Genu recurvatum with club-foot.) 



these measures apparatus should be applied to limit the lateral motion if 
it is present, restricting the amount of hyper extension and increasing 
the amount of flexion. Apparatus must be worn, of course, till the 
33 



514 



ORTHOPEDIC SURGERY. 



structures about the joint have adapted themselves to the new condi- 
tion. 

Posterior dislocation of the tibia on the femur occurs at times. 
Lateral subluxation may be found in connection with other congenital 
deformities. 1 

PATELLA. 



Dislocation of the patella is among the more common of the con- 
genital dislocations; many cases reported as congenital have, however, 
been doubted. 

The type most frequently seen is outward dislocation existing with 
some degree of knock-knee. It may be displaced inward or upward, in 

the latter case being associated with 
lengthening of the patella tendon. 
There may be, in connection with 
the dislocation outward, absence or 
flattening of the outer condyle of 
the femur. 

The disability may be slight or 
there may be marked impairment of 
the extension power of the leg on 
the thigh. Treatment by operation 
would be similar to that described 
in speaking of slipping patella. 

Congenital Absence of the 
Patella. 2 

The patella may be absent or 
tardy in its development. If it is 
absent the knee appears broad and 
flat and there may be marked im- 
pairment of the function of the 
knee. In other cases the knee is 
useful. It may coexist with other 
malformations of the knee, espe- 
cially genu recurvatum. It is often bilateral and is frequently associ- 
ated with club-foot and similar deformities. 

The treatment consists of apparatus to support the defective joint 
and massage and muscle training to the extensor muscles. 




Fig. 458. 



Congenital Dislocation of both Knees 
with Club-foot. (Reiner.) 



1 Cone: Am. Medicine, November 5th, 1904. 
-A. Thorndike : Orth. Trans., vol. xi. 



p. 812 (with literature). 



CONGENITAL DISLOCATIONS. 515 

ANKLE. 

Inward and outward congenital dislocations of the ankle have been 
recorded in connection with absence of the tibia or fibula. 1 

SHOULDER. 

True congenital dislocation of this joint is rare, and many cases re- 
ported as congenital have proved on investigation to be dislocations due 
to paralysis or due to injury to the shoulder at birth, resulting most 
often in a separation of the epiphysis. The dislocation found is the 
subspinous, but other varieties have been recorded, such as the sub- 
coracoicl and subacromial. Double dislocation of the shoulder has 
been described and in some cases associated with other malformations. 
In one case two children in one family were similarly affected. The 
glenoid cavity is likely to be malformed, as in a case reported by Smith, 
where there was hardly a trace of the normal glenoid cavity. In other 
cases it is approximately normal. The limitation of function is similar 
to that in traumatic dislocations. Cases of dislocation of the shoulder- 
joint in young infants have been reduced with or without incision, with 
improvement in the usefulness of the arm; cases of true congenital dis- 
location, however, improved by operation are few. Cases were oper- 
ated on by Phelps by doing what was practically an arthrodesis through 
a posterior incision, and the redundant capsule was removed. Some 
similar cases have been reported, but most of them are open to the sus- 
picion of not having been congenital. The chances of successful re- 
placement would be greater in cases with a normal glenoid cavity and 
in cases undertaken early in life. In later childhood the prospect is 
less good. 

In addition to the operative reduction, reduction by manipulation is 
to be considered, following the lines indicated in the operation for con- 
genital dislocation of the hip. After replacement the arm should be 
held by a plaster bandage for some months in a position of abduction 
and outward rotation. 2 

ELBOW. 

Congenital dislocations of the elbow are very rare and of compara- 
tively little practical importance. The reported cases do not conform 
to any one type, following a wide range of variation. 

1. Both bones may be dislocated forward or backward. This condi- 
tion is extremely rare. 

1 Freiberg : Amer. Jour, of Orth. Sur. , vol. i., No. 4, p. 335. 

-Whitman: "Orthopedics," second edition, p. 473. — Porter: Orth. Transac- 
tions, xiii., 1898.— Cumston: Amer. Jour, of the Med. Sciences, June, 1903. — Kir- 
misson: "Traitedes Mai. chir. d'Origine Congen.," Paris, 1898, p. 485. 



516 ORTHOPEDIC SURGERY. 

2. The displacement of the head of the radius is a more frequent 
form of dislocation and may occur on both sides. The dislocation may 
be backward, forward, or outward, with or without abnormality of the 
other bones of the arm. 

3. Backward dislocation of the radius and partial dislocation of the 
ulna with imperfect development of the external condyle have been 
recorded. The displacement may or may not be seriously disabling. 
In cases requiring radical operation, the head of the radius or the entire 
elbow-joint may be resected. 

Cubitus Valgus— Cubitus Varus. 

In connection with congenital dislocation of the elbow may be men- 
tioned a deviation from the normal line of the arm occasionally seen. 
If the arm of the adult hangs at the side with the palm of the hand 
directed forward, the line of the forearm should form with the line of 
the arm an angle of about 169 degrees with a variation of 10 degrees in 
either direction. The outward deviation of the forearm is a few degrees 
greater in women than in men. Cubitus valgus is the name applied to 
the condition in which the forearm is displaced too far to the radial 
side ; cubitus varus, the condition in which it is displaced to the ulnar 
side. Trauma is the most frequent cause of the marked varieties. 
They are also associated with rickets and the element of inheritance 
apparently plays a part. In case either deformity should be severe 
enough to require operative treatment, an osteotomy may be done simi- 
lar to the Macewen operation for knock-knee. 

WRIST. 

Pure congenital dislocation of the wrist is extremely rare. The 
ordinary form in. which it is seen is in connection with club-hand. 

Spontaneous Subluxation of the Wrist. 

A displacement of the wrist has been described by Madelung, 1 in 
which the hand is displaced to the palmar side of the forearm and prob- 
ably to either the radial or the ulnar side laterally, generally to the former. 
In such cases the lower border of the radius and that of the ulna are 
prominent at the dorsum of the wrist, and the bones are somewhat sep- 
arated from each other. The wrist is much increased in thickness and 
the function of the hand is impaired. Active and passive dorsal flexion 
are affected and some pain may be present, especially in dorsal flexion. 
The hand can be replaced only in the lighter grades of the affection. 
There is excessive mobility of the intercarpal joint and there may be 
slight forward bending of the lower extremity of the radius. 

1 Archiv f. klin. Chir. . Bd. xxiii. 



CONGENITAL DISLOCATIONS. $17 

Aside from the pain which may be present, the symptoms are 
weakness and sensations of discomfort about the wrist. The causes of 
the affection are given as relaxation of the ligaments, stretching of the 
muscles by hard work, irregularity of growth at the lower end of the 
radius, and possibly a malposition lasting over from rickets. The treat- 
ment is at first hyperextension of the joint by means of bandages and 
splints, the use of massage and similar measures, and osteotomy in 
cases with bony deformity sufficient to require it. 



CHAPTER XIX. 
TALIPES. 

Talipes equino-varus (Club-foot). — (Pathology. — Etiology. — Symptoms. — Diag- 
nosis. — Prognosis.— Treatment. )— Talipes equinus (Varieties.— Etiology. — 
Pathology. — Symptoms. — Treatment). — Talipes calcaneus (Varieties. — ' 
Symptoms. — Treatment). — Talipes valgus. — Talipes varus. — Talipes cavus. 

Club-hand (Varieties. — Etiology. — Symptoms. — Diagnosis. — Treatment). 

The name talipes signifies a deformity of the foot, and, although it 
was originally used to indicate a form of talipes now known as equino- 
varus or club-foot, the present use of this word is as a prefix to the de- 
scriptive adjective designating the variety of the deformity which exists. 
Of the pure forms of talipes one finds described talipes equinus, the 
plantar-flexed foot ; talipes calcaneus, the dorsally flexed foot ; talipes 
cavus, the foot with increased arch ; talipes valgus, the everted foot ; 
and talipes varus, the inverted foot. 

Talipes equinus may exist with either valgus or varus, being then 
spoken of as equino-valgus or equino-varus, the elements of two de- 
formities being present. Talipes calcaneus may exist in connection 
with valgus or very rarely with varus, being then known as calcaneo- 
valgus or calcaneo-varus. 

TALIPES EQUINO-VARUS (CLUB-FOOT). 

The term club-foot is popularly applied to a deformity characterized 
by an inversion, torsion, and depression of the front part of the foot 
with an elevation of the heel. 

In walking on a foot thus deformed, the weight of the body is borne, 
not by the sole of the foot, but by the outer side, and in extreme cases 
by the dorsum of the foot. 

The distortion is also known as "reel" foot — pes contortus, 
Klump-Fuss, pied bot, etc. 

The deformity is either congenital or acquired. 

Frequency. — Club-foot is by no means an uncommon distortion, 
and was mentioned in literature even in the days of Homer. 1 In 6,969 
orthopedic patients applying at the out-patient department of the Chil- 
dren's Hospital, Boston, there were 488 cases of club-foot. Congenital 
club-foot is by far the most frequent of the congenital deformities of 

111 Iliad," i., 599; xxi., 331. 
518 



TALIPES. 



519 



the foot. It affects males more frequently than females, and the right 
foot is more frequently affected than the left. It is as often double as 
single. Acquired club-foot affects males and females in about equal 
proportion, the right foot is most often affected, and it is more fre- 





FlG. 459. 



-Section of Foot and Leg 
in Club-foot. 



Fig. 460.— Section of Foot and Leg, 
Normal. 



quently unilateral than bilateral. Chaussieur, among 22,923 newly 
born infants, reports 37 cases of club-foot. Lannelongue, among 
15,229 births at the Paris Maternity Hospital, found 8 cases. 

Pathology. — The deformity is a dislocation inward of the anterior 
part of the foot, the dislocation taking place at the medio-tarsal articu- 
lation. All the tissues are necessarily affected by the abnormal posi- 
tion, and the skin, muscles, tendons, and fasciae are all altered. 

In all cases of congenital club-foot, even in that of a full-term foe- 
tus, the scaphoid bone will be found articulating with the side of the 





Fig. 461.— Relation of Astragalus to Os 
Calcis. (Whitman.) 



Fig. 462.— Relation of Astragalus to Os 
Calcis in Flat-foot. (Whitman.) 



head of the astragalus rather than with the anterior surface. The 
articulation is also more toward the under side of the astragalus, the 
head of which is thus uncovered. 

The scaphoid may be so far distorted to the side as to articulate at 
one end with the tip of the internal malleolus. The cuneiform bones, 
being intimately connected with the scaphoid, follow the displacement 
of the latter, and the same is true of the metatarsal bones and the pha- 



520 



ORTHOPEDIC SURGERY 



langes, so that the long axis of the front of the foot forms a right angle, 
or even an acute angle, with the axis of the leg. The cuboid is neces- 
sarily displaced to the inner side and does not articulate with the front of 
the os calcis, the facet of which also inclines obliquely to the inner side. 

In fully developed cases, and in older children or adults, there is a 
more marked and important alteration in the shape of the bones. 

The os calcis, by the elevation of the tuberosity, is drawn from a 
horizontal into a position approaching the vertical. It is also more or 
less rotated on its vertical axis, so that its anterior extremity is directed 
outward and the posterior extremity inward, and thus the anterior artic- 
ulating facet is oblique to the axis of the bone. The cuboid bone main- 




FiG. 463.— Dissection of Club-foot. 



tains its connection with the os calcis, but follows the inward direction 
of the anterior extremity of the foot. 

There is no rotation of the astragalus on the vertical axis, but, as 
has been stated, it is depressed forward on its horizontal axis, so that 
only the posterior portion of its superior articular surface is in contact 
w r ith the inferior articular surface of the tibia, and the anterior part of 
its anterior facet projects beneath the skin of the dorsum of the foot. 
Besides this displacement, the shape of the bone is altered by the 
twisting inward of the head and neck, so that the anterior articular sur- 
face looks inward instead of forward, and the disposition of the carti- 
lage at the articulating surfaces of the head of the astragalus is neces- 
sarily altered. The three cuneiform and the three metatarsal bones, 
being closely connected with the scaphoid, are more twisted to the in- 
side than is the case with the cuboid, though the metatarsals are not all 



TALIPES. 



521 



equally involved in the rotation from without inward and are spread out 
something as the branches of a fan, in such a way that the anterior part 
of the foot is enlarged more than normal. Besides these alterations in 
the position of the foot others take place secondarily, depending on 
pressure and the effect of locomotion on the distorted bones. 

The different tendons assume an abnormal direction and in general 
are carried farther to the inside than is normal ; this is especially true 
of the tibialis anticus, the common extensor of the toes, and the long 
extensor of the great toe. Synovial bursse may form on the outer 



HT 




W ' 




m f 






Mm 



Fig. 464. — Double Congenital Club-foot. 



edge and back of the foot, which may become inflamed and suppurate ; 
corns and callosities are also formed on the skin, from the pressure of 
walking. No change has been found in the nerves or the spinal cord in 
cases of club-foot. 

In extreme cases there may be slight alteration in the shape of the 
femur and a laxity at the knee-joint; the tibia has also been found al- 
tered, and the same is true of the fasciae. The muscles are never found 
paralyzed in congenital club-foot, but the contracted muscles seem more 
developed than the lengthened muscles. The muscles of the leg atro- 
phy from disuse, and the leg is much smaller and the foot shortei than 
normal. 



522 ORTHOPEDIC SURGERY. 

In addition to the faulty shape of the bones there is a change in the 
ligaments and fasciae, and this is not confined to the severe and most 
inveterate cases, but is always present. Not only are the plantar liga- 
ments and fasciae contracted, but the internal lateral and posterior liga- 
ments are also contracted. 

Etiology. — In regard to the etiology of congenital club-foot, various 
theories have been advanced in explanation of the deformity. 

A popular idea is that the distortion is due to maternal impressions, 
but no conclusive evidence in regard to this has been obtained. 1 

Heredity, on the part of both the father and mother, has been 
established without doubt in a certain number of cases, but in a very 
large majority no trace of similar deformity in ancestors can be found. 

The chief theories which have been advocated to explain the de- 
formity in uterine life are as follows : 

First. — Abnormal compression in the uterine cavity. 

Second. — Retraction or paralysis of muscles depending or not on 
lesion of the nervous system occurring in utero. 

Third. — A malformation depending upon arrest of development of 
the foot. 

With regard to these theories it may be said that abnormal com- 
pression of the uterine walls may be a factor in producing the deformity, 
that evidence of muscular paralysis is wanting, and that the evidence 
that club-foot is due to a retarded rotation of the foot 2 and is the persis- 
tence of a foetal condition is not supported by good evidence. 3 

It may be said that we are entirely ignorant of the causation of 
club-foot, and unable to give a reasonably satisfactory explanation of 
the phenomena of its development. 4 

Symptoms. — Club-foot gives rise to great inconvenience in walking. 
In uncorrected cases, however, the amount of skill and agility patients 
acquire in locomotion is surprising, even though the deformity remains 
unchanged. Bursae and callosities form over the unprotected portions 
of the foot, and may inflame and cause much discomfort, limiting the 
amount of the patient's activity. A laxity of the knee-joint is some- 
times developed in consequence of club-foot. 

The gait of these patients is characteristic. In double cases the 
feet are lifted one over the other as a step is taken, giving a peculiar 
appearance, and perhaps suggesting the popular name of "reel" feet. 
The tendo Achillis is firm and hard to the touch ; the plantar fascia 

1 Dabney : '' Cyclopedia of Diseases of Children," vol. i. 

2 Brit. Med. Journ., 1886, ii. io; Archives of Med., New York, Dec. i, 1882; 
Boston Med. and Surg. Journ., Oct. 27, 1887. — Wolff: " Ueber die Ursachen, etc., 
des Klumpfusses," Berlin, 1903. 

3 Bessel Hagen : " Die Path, und Therap. des Klumpfusses," Heidelberg, 1899. 

4 R. W. Parker and Shattuck : Brit. Med. Jour., May 24th, 1SS4, p. 998. 



TALIPES. 



523 



will be found short and hard on palpation. The front of the foot pro- 
jects to the inside of the vertical axis of the leg, the posterior end of 
the os calcis is raised and turned inward, the leg is turned outward, 
and the head of the astragalus and cuboid project under the skin. 
There is usually atrophy of the muscles of the leg. The external mal- 




FlG. 465. — Congenital Club-foot. Cured club. Twenty-four years after correction in infancy 
by tenotomy, manual force and retention, walking appliance worn for two years. Patient 
able to walk without limp or discomfort twenty miles a day. 

leolus is prominent and the internal malleolus not readily felt. The 
foot is more or less rigid in the deformed position, resisting gentle 
attempts at correction. 

Diagnosis. — There is no difficulty in recognizing the deformity of 
club-foot. In infancy, a true club-foot is sometimes thought to exist 
when the trouble is simply a temporary spasm of the tibialis muscles 
which turn the foot in. This passes away in a short time and should 
occasion no anxiety. 

The history of the case establishes a diagnosis between the congeni- 
tal and non-congenital forms of club-foot. The paralytic form can be 



524 



ORTHOPEDIC SURGERY, 



recognized by the evidence of paralysis of the muscles on the anterior 
and external surface of the leg. Paralysis, it may be added, is the only 
common cause of acquired club-foot. The severity of cases of club- 
foot cannot be determined always by the apparent distortion. Cases 
resembling each other in outward appearance may prove less or more 
difficult of treatment. As a rule, however, it may be said that the 
younger the patient the less resistant the deformity, and it is often con- 
venient to consider the cases as : 

i st. Infantile — i.e., infants in arms. 

2d. Walking cases— i.e., cases in young children in which the feet 
have been walked upon before the deformity has been corrected. 





Fig-. 467. 



Fig. 468. 



Fig 4 65. 

FIG. 466. — Diagram Indicating Mid-tarsal Articulation in Club-foot and the alteration in the 

positions of the scaphoid and cuboid in their relation to the astragalus and os calcis— with 

alteration in the shape of front of oscalcis. 
FIG. 467.— Diagram of a Normal Foot. 
FlG. 468. —Diagram of a Club-foot Partially Corrected, Leaving the Projection of Front of Os 

Calcis Unchanged, and the Consequent Imperfect Reduction of the Cuboid. A relapse 

necessarily follows. 



3d. Resistant or relapsed cases — i.e., those which have resisted 
treatment, or in which treatment has been inefficient, and in which the 
deformity has recurred. 

4th. Neglected cases/in which the feet have grown for years in a 
severely distorted position. 

Prognosis. — In regard to the prognosis of the deformity, it may be 
said that the distortion does not correct itself, and, if left uncorrected, 
remains the most obstinate of malformations. The deformity is one 
which is essentially curable; in fact, it may be said that it is always 
curable, provided care and attention can be given by both surgeon and 
nurse. 



TALIPES. 525 

The amount of time needed for treatment varies according to the 
method employed. Formerly much time was needed in the treatment 
of inveterate cases, but since the introduction of open incision and tarsal 
resection, when necessary, correction can be accomplished in a short 
time. 

In infantile cases the time required for correction is relatively short, 
but retentive appliances are needed for a longer time. It ma)- be said 
in general that the older the cases and the larger the foot the more 
difficult the correction, but the less the danger of relapse after correc- 
tion. 

In regard to the permanence of the cure and the danger of relapse, 
it may be said that if perfect correction is attained relapse is excep- 
tional, if moderate care is used in the employment for a sufficient time 
of retentive appliance. 1 

But it must be borne in mind, especially in the case of young chil- 
dren, not only that the correction must be complete, but that efficient 
appliances for keeping the proper position of the foot in walking (reten- 
tive or walking appliances to be described) must be worn until the gait 
and attitude are perfect. In club-foot half-cures are practically no 
cures. Relapsed cases are invariably resistant and difficult to correct. 

Treatment. — The object of treatment is the correction of the distor- 
tion and the retention of the foot in a corrected position until any re- 
turn of the deformity is impossible, the tendency to relapse being very 
strong. 

The treatment should be purely mechanical, or both operative and 
mechanical. 

The treatment of club-foot, therefore, requires: 

1. A rectification of the misplaced bones and a lengthening of short- 
ened and contracted tissues. 

2. A retention in a normal position until the abnormal facet of the 
astragalus and the other tissues become, under the pressure of new po- 
sition, normal. 

At the present time few procedures in surgery are as precise in their 
indications and as certain in their results as the methods for the cor- 
recting of club-foot. 

The correction of club-foot should be divided into two steps, whether 
the treatment is mechanical or operative. 

1st. Correction of tne varus deformity. 

2d. Correction of the equinus deformity. 

In other words, the front of the foot should be twisted out and after- 
ward be raised. This will be found of practical importance, as the foot 
is more easily twisted before than after the equinus deformity is over- 
come. 

1 Trans. Am. Orthop. Assn., vol. i . "Club foot." 



526 



ORTHOPEDIC SURGERY. 



Operative treatment in some form is the method to be selected in 
cases of congenital club-foot, except in young infants and in older chil- 
dren when some contraindication to operation exists. 

The mechanical procedures for correcting club-foot are as follows : 

Manual manipulation. 

Plaster-of-Paris bandages. 

Apparatus. 

The operative procedures which are to be considered in treating 
club-foot are : 

Tenotomy. 

Division of the ligaments. 

Open incision. 

Forcible correction and osteotomy. 

Mechanical Correction. 

Manual. — The simplest method of correction is by the use of the 
hands, and in the case of a new-born infant with club-feet the mother 
may be directed to manipulate the foot, and having rectified the de- 




Fig. 469.— Double Club-foot in Plaster Bandages After Operative Correction. 

formity by gentle force several times daily, to hold it as straight as 
possible for a minute or two each time. This process continued daily 
over a period of months is in intelligent hands capable of restoring the 
foot to its normal mobility and position, after which retention treat- 
ment should be begun. 



TALIPES. 



527 



Plastcr-of-Pai is Bandages. — Another method in correcting club-foot 
is by repeated fixation in a plaster-of-Paris bandage, the foot being held 
as nearly in a corrected position as possible at each application of the 
bandage until the bandage hardens. The application of a plaster-of- 
Paris bandage must, however, be made with care and skill to prove effi- 
cient, whether applied for correction 
without operation or to maintain the 
overcorrected position obtained by op- 
eration. 

The foot should be wound with 
plenty of sheet wadding, pads should be 



« 1 




FIG. 470-— Congenital Double Club- 
foot Walking Before Operation. 



FIG. 471.— Double Club-foot. Two months after correction 
by forcible manipulation, wearing walking retentive 
appliances. Same case as Fig. 470. 



placed between the toes, and the foot should be held overcorrected 
from the first during the application of the bandage by an assistant, 
who shifts the fingers from place to place to keep out of the way of the 
bandage, yet who maintains the overcorrection. To overcorrect the 
position of the foot when the plaster is setting is to cause folds of the 
bandage to turn in and either compress or cut the tissues after the plas- 
ter is set. It is important to keep the inner end of the foot part of the 
bandage long, to press outward the front of the foot, and thus antago- 
nize the varus. 



5- 



ORTHOPEDIC SURGERY. 



The circulation of the toes must be carefully watched after the ap- 
plication of such a bandage. 

An extension of this method is to be obtained after the plaster has 
set by removing an elliptical piece of the plaster bandage over the an- 
terior and outer aspect of the ankle and dividing the rest of the band- 
age at the same level by a circular cut. By crowding the front of the 
foot-piece up and out and holding it in the improved position by fresh 
bandages applied over the old plaster, further correction is obtainable. 





FIG. 472.— Splints for Equino-varus Applied. 

The bandage should reach above the knee, where the limb should 
be slightly bent to prevent the plaster bandage (which should be re- 
newed every two or three weeks) from rolling around the limb, and to 
prevent the child from kicking it off. In the case of small children 
with plump legs, and in resistant cases, it will, however, be found diffi- 
cult to prevent the heel from being drawn away from the bandage, and 
stretching of the tendo Achillis will by this method be tedious. 

This method has the disadvantage of being tiresome, but it has 
many advantages in being a practical method, readily applied, and not 
leaving details of application to the patient's parents. It is evident that 



TALIPES. 



529 



correction in this way, if persistently applied, is possible, but, except in 
very young children, it is advisable to perform tenotomy first. If the 
Chinese 1 can produce an extreme deformity by bandaging the children's 
feet, the same method could be employed for the correction of deform- 
ity. 

Apparatus. — Mechanical correction (without tenotomy) by means 
of appliances has been successfully employed in very young cases. 
The method, however, requires much persistence on the part of the 
surgeon if a perfect cure is expected, and is not to be advised. 

Although treatment by apparatus is not sufficiently effective to cure 
an)' but the mildest forms of congenital club-foot in young children, it 
is often enough to bring about a cure in acquired club-foot of moderate 
severity. The form of apparatus is the same whether used as a correc- 
tive or as a retentive appliance, and will be described here. The object 
of such apparatus is to retain the tarsal bones in proper position until 
the muscles and ligaments have adapted themselves to the normal posi- 





FlG. 473.— Taylor Shoe in Process of Adjust- 
ment. The sole plate applied and the foot 
strapped to the sole plate. 



FIG. 474.— The Upright Brought into Place 
and Acting as a Lever, Turning the Foot 
to the Outer Side. 



tion, and until articular facets have been formed in the proper directior, 
or the astragalus and os calcis have assumed, under altered pressure, a 
relatively normal shape. 

Corrective apparatus is essential after the desired position of the 
foot has been obtained by other means. 

The corrected foot tends to relapse in two directions — inversion and 
elevation of the heel. If this is unchecked and walking is done in im- 
proper attitudes, hurtful pressure and strain fall upon the bones and 
ligaments of the foot, and relapse takes place. This should not occur 
if proper retention and walking with a proper attitude of the foot are 
cared for. 

As these appliances are to be worn a long time, they should be light, 
readily adjusted by the nurse, not unsightly, and in no way limiting lo- 
comotion, walking, or running. The best are worn within the shoe. 



34 



1 Percy Brown : Journal of Med. Research, 1904. 



53° ORTHOPEDIC SURGERY. 

It is unnecessary to describe all the various appliances that have 
been used. Mention will here be made of one which has been found of 
service in the writers' experience, after a careful trial of the usual vari- 
eties of appliances designed for the purpose. 

It is to be remembered that in all appliances it is necessary that the 
pressure preventing a faulty position of the foot should be applied pre- 
cisely, pressing the front of the foot and tip of the heel outward, the 
front of the foot, especially the outer edge including the cuboid, upward, 
and the back of the foot, i.e., the end of the os calcis, downward, and 
the outer dorsum of the foot inward. 

Inward pressure should be exerted upon the outer edge of the front 
of the os calcis and astragalus, and not upon the cuboid, as is too com- 
monly done in inefficient apparatus. As the latter bone is in front of 
the mediotarsal joint, inward pressure upon it not only fails to correct 
the deformity but tends to increase it. This explains the occurrence of 
many relapses. 

The apparatus (Chapter XXI., 27), which is a modification of Tay- 
lor's varus shoe, consists of a sole plate small enough to fit in a shoe 
secured to a jointed upright furnished with a stop to prevent the plate 
from dropping into the equinus position. The foot is secured to the 
plate by means of a strap which, secured to the inner side of the plate, 
passes from the inside of the great toe obliquely to the outside of the 
foot so as to press upon the anterior outer surface of the os calcis and 
through a loop at the outside, and then is brought across the ankle 
through the metal loop and secured in the clasp. A cross strap to 
keep the toes down, and a cross ankle strap to keep the heel down, are 
sometimes necessary in addition, with a back strap behind the heel. 

The appliance can be worn inside of a shoe, opened like a bicycle 
shoe well down to the toes. 

A combination of operative and mechanical methods of treatment is 
at present the most common mode of treating club-foot at all ages. 
The operative interference most frequently resorted to is tenotomy and 
subcutaneous division of the fasciae or ligaments. 

Operative Treatment. — Tenotomy. — The structures to be di- 
vided are, of course, those which hold the foot in its deformed position. 
The tendons may be divided by entering the tenotome under the 
skin and cutting the tendon from without inward, or by passing the 
tenotome under the tendon and cutting outward. The advantage of 
the former is that there is no clanger of making a large skin incision by 
a slip of the tenotome. There- is, however, danger of incomplete cut- 
ting of the tendon. The tendon which is most frequently divided in 
equino-varus is the tendo Achillis. 

Section of the Tendo Achillis. — -The patient should lie upon his face 
or side and an assistant should bold the foot; the surgeon enters the 



TALIPES. 



531 



knife parallel to the border of the tendon, passing the tenotome flatwise 
between the tendon and the skin. This having been done, the blade of 
the knife is turned toward the posterior surface of the tendon and the 
assistant raises the end of the foot so as to stretch the tendo Achillis 
slightly. The left index finger presses on the skin over the back of the 
tenotome, and in this way the sensation of the cutting of the tendon 
can be felt. 

The only precaution necessary is to be assured that the tendon is 
completely divided. When the operation is done, the extravasated blood 
is squeezed out of the opening and a small amount of aseptic gauze is 
placed over the wound. The operation should be done aseptically and 
an aseptic dressing applied. 

Section of the Tibialis Posticus. — Section of the tibialis posticus is 
done in the following way : If the muscle is divided in the leg, the foot 
is placed on its external border. The surgeon divides the skin by 





Fig. 475- 



Fig. 476. 



Fig. 475. — Imprint of Foot of a Child Sixteen Years Old. Treated when one year old for con- 
genital club-foot. 
FlG. 476. — Imprint of Normal Foot. 



means of a pointed tenotome 2 cm. above the tip of the internal malle- 
olus and on a vertical line situated half-way between the posterior bor- 
der of the malleolus and the corresponding border of the tendo Achillis. 
The tenotome should be directed perpendicularly downward to the 
depth of 1 or 1.5 cm. Then the handle of the instrument should be 
turned so as to describe the arc of a circle and the tendon divided ver- 



53- 



ORTHOPEDIC SURGERY. 



tically inward. The assistant at the same time turns the foot forcibly 
in the direction of abduction. If the incision is made too near the mal- 
leolus, the internal saphenous vein and nerve may be cut. If the inci- 
sion is made too near the tendo Achillis, there is danger of dividing the 
tendon of the long flexors of the toes and the posterior tibial artery and 
nerve. 

The writers can record the puncture of the posterior tibial artery 
by the point of a tenotome and the formation of a small aneurism which 
required ligation, but caused no subsequent annoyance. 

The Tendon of the Tibialis Anticus. — The tendon of the tibialis an- 
ticus is divided more easily. For this purpose it is sufficient to b^ 




FlG. 477. — Relapsed Resistant Congenital Club-foot in a Boy of Eight. Front view. 



guided by the prominence of the tendon put on a stretch by abducting 
the foot. To avoid the wounding of the deep parts, it is better to enter 
the tenotome under the tendon. 

Division of the Plantar Fascia. — It is often necessary to divide also 
the plantar fascia, preferably before division of the tendo Achillis, as 
the latter acts as a means of support for stretching the foot when the 
plantar fascia is divided. The plantar fascia is divided in the same way 



TALIPES. 



533 



that the tendons are incised. The most prominent portion of the fas- 
cia is the point of election for subcutaneous incision. The fascia, it 
must be borne in mind, is not a narrow band, but a broad ligament 
needing a long subcutaneous incision. The tenotome should be inserted 
on the inner side of the sole nearly half-way between the os calcis and 
the ball of the foot, but nearer to the os calcis. The tenotome is to be 
pushed subcutaneously nearly across the sole, the edge of the knife 




Fig. 478.- Same Case. 



Three weeks after forcible correction, immediately after removal of 
plaster retention bandages. 



turned toward the fascia, and the knife drawn across the fascia, which 
will be felt to give way as it is divided ; an assistant should make up- 
ward pressure upon the ball of the foot, in order to put the fascia on 
the stretch. As the artery lies deeply, there is no danger of injuring 
it, if ordinary care is used. 

The tenotomes used should be strong at the neck, and the cutting 
edge should not be too long, as the skin is necessarily divided if they 
are too long; infantile cases require a much smaller instrument. The 
blunt-pointed tenotome is but little used now, and the sharp-pointed 
ones are used for all subcutaneous work. 

Tenotomes as furnished by instrument-makers are ordinarily much 
too large, and though serviceable in myotomy, are better for tenotomy 
in children if smaller. 

TJic Repair of Divided Tejidons} — When a tendon is divided, the 
1 Seggel : Beitr. z. klin. Chir., xxxvii. , 1 and 2. 



534 



ORTHOPEDIC SURGERY. 



cut ends are separated to a variable extent, depending upon the retrac- 
tion of the muscle to which it belongs, upon the position in which the 
limb is placed, and upon the surrounding attachments of the tendon. 
Extending beneath the ends of the tendon is its tubular sheath of con- 
nective tissue, and it is this which chiefly furnishes the reparative mate- 
rial. 

The sheath becomes vascular and succulent, and after the absorp- 
tion of the blood that has been effused within it, the interval between 




FIG. 479. — Relapsed Resistant Congenital Club-foot in a Boy of Eight. Rear view. 



the divided ends of the tendons becomes filled with lymph, which grad- 
ually becomes fibrillated and forms a firm bond of union between them. 

The new material so closely resembles the old tendon and is so in- 
timately blended with it that for a time it would be difficult to distin- 
guish them, except for a certain translucency which is possessed by the 
former, and is not natural to the latter. By this means the divided ten- 
don is increased in length to the extent of the interval by which its 
ends are separated, and elongation will vary according to the amount of 
separation. 

If after the operation treatment is carried out with ordinary care 
and skill on a healthy subject, a useful muscle is obtained. 



TALIPES. 



535 



Adhesions may, and doubtless often do, form between the divided 
tendons and the surrounding structure, but in ordinary cases they are 
not of consequence, for they give way in the use of the foot, and do not 
interfere with the function of the muscle. 

Much undeserved opprobrium for a time fell upon the procedure of 
tenotomy. In half-cured and relapsed cases atrophy and functional dis- 
ability of the muscles will be found ; but there is no evidence to de- 
monstrate that tenotomy, when properly performed, exerts an unfavor- 
able influence upon the muscle. 

Division of the Ligaments. — Division of the ligaments x is of use in 
the correction of club-foot. 

For division of the astragalo-scaphoid ligament, the skin and soft 
tissues should be punctured down to the bone by the insertion of the 




Fig. 



-Soles of Relapsed Resistant Congenital Club-foot in a Boy of Eight. 



tenotome. It should then be inserted in front of the internal malleolus 
and pushed directly to the underlying bone, and swept subcutaneously 
around the bone, keeping close to it. The knife should be kept between 
the skin and ligaments, and the latter divided by a sawing motion of the 
tenotome. This division, if satisfactorily and thoroughly made, may 
serve in certain cases as a substitute for the division of the tibialis ten- 
dons. 

The calcaneo-cuboid ligament should also be divided in severe cases. 
The tenotome should be inserted a short distance behind the head of 
the fifth metatarsal bone, near the articulation of the os calcis and 
cuboid, which can be felt on palpation. The sharp-pointed tenotome 
should be inserted to the bone, and then by careful motion the whole 
ligament should be divided. 

1 London Path. Soc. British Med. Jour.. 1SS6. vol. ii.. p. 10. 



53 6 ORTHOPEDIC SURGERY. 

Subcutaneous tenotomy of all the parts which obstruct the complete 
restoration is performed. This in most cases consists of division under 
an anaesthetic of the plantar fascia, the ligament of the scapho-astraga- 
loid joint, and last, the tendo Achillis. After the tenotomy of the first 
three the foot is forcibly corrected by the hand, and a division of the 
resisting parts carried to such a point that the foot can be easily brought 
beyond the normal plane, after which tenotomy of the tendo Achillis is 
done and the foot placed in plaster in an overcorrected position. 

In case the restoration has not been perfect, as sometimes happens 
with more resistant feet, it is well to remove the plaster at the end of 
ten days and apply the brace which is to be worn, reapplying the ap- 
paratus every two or three days. In this way, before complete consol- 
idation has taken place, a certain amount of gain can be made and over- 
correction be obtained at the end of a few weeks, which at first was 
impossible. If, however, the restoration has been complete it is better 
to keep the bandages on for from six to twelve weeks, in order that the 
foot may not be disturbed from its overcorrected position. When the 
bandages are removed great care should be taken that the foot is not 
allowed to drop from its overcorrected position, and thus make traction 
on the ligaments and soft parts in which contraction is desired. 

When the plaster bandages are removed the retention appliance, 
described above, is to be used so long as there is any tendency to an 
incorrect position. 

The permanence of the correction depends on the establishment of 
an accurate balance of the antagonism of muscles and other soft parts 
when the foot is in normal position. The after-treatment by retention 
must be persisted in until the child is able, without special effort, to 
walk with the foot in a natural position ; otherwise a relapse will occur. 

The sooner the foot is corrected the better, provided the patient's 
general condition is satisfactory, and that treatment is not liable to be 
interrupted by intercurrent infantile disorders; practically, treatment 
should be undertaken as soon as an infant is nursing well and is in rea- 
sonable health. 

The use of retention apparatus will be necessary for some years and 
should be discontinued gradually. The parent may aid in the treatment 
by daily manipulating the feet into the overcorrected position. The 
treatment described covers in general all that is necessary for infantile 
club-foot. 

The length of time during which the appliance is needed in after- 
treatment varies and is in general in inverse proportion to the size of 
the foot or the difficulty of correction, infants in arms needing a reten- 
tion appliance relatively longer than is necessary in adult cases, in 
which, if correct gait with proper weight-bearing upon the sole is se- 
cured for a few months, relapses are not to be expected. 



TALIPES. 537 

Summary of Mechanical Treatment. — In simple cases one may 
attempt correction (i) by manual manipulation repeated several times 
daily, (2) by plaster bandages applied at intervals of two or three 
weeks, (3) by the use of a corrective brace constantly worn, (4) by the 
subcutaneous division of tendons, fasciae, and ligaments followed by 
immediate overcorrection in a plaster bandage. Without after-treat- 
ment relapse will follow in practically all cases. After-treatment con- 
sists in the use of a retention brace and daily manipulation of the foot. 

Operative Correction. 

In cases too resistant to be corrected by the means described the 
following radical measures may be employed : 

1 st. Open incision. 

2d. The use of extreme force. 

3d. Tarsal osteotomy. 

Open Incision. — The chief difficulty is in obstinate cases to stretch 
the contracted tissue on the concave side of the distortion. Phelps' 
open incision on the inner and plantar surface is of use in these cases. 

The advantage of open incision in club-foot is the facility of com- 
plete and thorough division of all the soft tissues to the bone. The 
method by which this is done is as follows : The skin is divided along 
the inner side of the foot, from the tip of the malleolus well down on 
the inner edge of the first metacarpal bone. After the skin is incised, 
the other tissues are cut with care, using a director if necessary. The 
insertion of the tibialis tendon is found and cut across. The artery can 
be spared by careful dissection, but if necessary it can be divided and 
tied. The plantar fascia on the sole of the foot should be divided by 
the use of a tenotome, or long, thin knife. A cross incision toward the 
sole of the foot from the middle of the long incision is sometimes nec- 
essary, but it is desirable to avoid this if possible. A triangular incision 
with its apex upward toward the ankle, instead of the cross-cut of the 
skin and fascia, is equally efficient and diminishes the gap after correct- 
ing the foot. 1 

Forcible Manipulation. — Even if tenotomy and thorough open 
incision are done, a certain amount of resistance remains from the in- 
terosseous ligament connecting the tarsal bones. Considerable force 
is often necessary to bring the foot into an overcorrected position. 
This can be done either by manual force or by the aid of mechanical 
force. Several wrenches for this purpose have been devised ; that of 
Thomas is the simplest and is sufficiently efficient when no bone ob- 
struction exists. The foot is then brought into as normal a position as 
possible, thorough aseptic dressings are applied, and the foot is then 

1 Jonas : Annals of Surgery, April. 1S97. 449. 



538 



ORTHOPEDIC SURGERY. 



fixed in a plaster-of-Paris bandage reaching above the knee and holding 
the well-padded and aseptically dressed foot in an overcorrected posi- 
tion. If the dressing is provided with efficient protectors and sufficient 
dressings, no change in the bandage need be made for a fortnight or 
longer. If necessary, however, a window can be cut in the plaster over 
the wound and the dressings changed. After the plaster of Paris is 
discarded the retention shoe is to be worn. 

The use of manual force without any previous cutting operation will 
rectify the deformity in club-foot, and such a method is in use. The 
inward twist of the foot, at the mediotarsal joint, is first corrected by 

if 





FIG. 481. -Thomas Club-foot Wrench, Modified. (Hoffa.) 

grasping the heel in one hand and the forefoot in the other and stretch- 
ing the inner side of the foot, either by the hands alone or by bending 
it over the padded edge of a triangular block of wood. 

The inversion of the sole of the foot is then corrected by a similar 
series of manipulations, until the sole of the foot is everted and will stay 
in that position without the use of force. 

The plantar fascia is next stretched and the height of the arch re- 
duced by flexing the foot dorsally against the force of the tendo A chillis. 

The reduction of the astragalus to its proper position between the 
malleoli is next undertaken. The tendo Achillis is divided by a teno- 
tome, and, if necessary, the posterior ligament of the ankle-joint. 



TALIPES. 



539 



The child is now turned on the face, and the front of the thigh lies 
on the table with the knee flexed and the leg vertical. The operator 
hooks his fingers around the os calcis while the hand lies on the sole of 
the foot to force it into dorsal flexion. This is done by a series of forci- 




FlG. 4S2.— Manipulative Correction of Club-foor. (After Lorenz.) 

ble pressings downward on the sole of the foot, until the dorsum- of the 
foot nearly touches the tibia. The foot is now limp and can be held in 
an overcorrected position without the use of force. In this position a 
plaster bandage is applied. 

The disadvantages of the operation lie in the unnecessary violence 
used to obtain a result which can more easily be reached by cutting re- 
sisting structures. The use of manipulative force is a well-recognized 
and useful preliminary to all forms of operation for club-foot. The 
experience of the writers has led them to prefer the removal of a wedge 




FlG. 483.— Lever Correction Apparatus (Applied), 

of bone to the use of extreme force in cases which are still resistant 
after the use of the measures just described. 1 

In applying the bandages, it is of course important that the foot 
should be held in an overcorrected position until the plaster becomes 
hard, as no further correction can take place under the bandage. In 
the majority of cases perfect correction or overcorrection is possible, 

1 Phillipson : Deut. Zeitschr. f. Chir., xxviii. 



540 



ORTHOPEDIC SURGERY. 



and the foot can be held in proper position for the application of the 
fixation bandage without much force. 

Osteotomy. — When but a slight amount of osseous distortion is 
present forcible correction aided by tenotomy or open incision will be 
sufficient to overcome the deformity, but in the more resistant cases 







flHHHl 




■^^ 






•. 


'*">" 





FIG. 484.— Double Congenital Club-foot Before Operation. 



changes in the shape of the tarsal bones forming the mediotarsal joint 
prevent perfect cure, and operation upon the bones is necessary. 

Astragaloid Osteotomy. — An examination of the anatomy of resist- 
ant club-foot shows that the facet of the astragalus in the astragalo- 
scaphoid articulation is on the side instead of in front. There is also 
some obliquity of the neck of the astragalus. If this obstruction of the 
bone can be corrected and the front of the foot brought into place, there 
would be less tendency to relapse. 

It is essential, in every inveterate case of club-foot, that if the foot 
is to be unfolded, the shortened tissues in the arch of the foot and in 
the inner side of the foot be stretched, torn, or divided. This can be 
done safely by means of tenotomy, forcible stretching, or open incision ; 



TALIPES. 



541 



but the deformity of the astragalus still remains. In many eases, even 
if somewhat resistant, if the deformity is rectified and the foot held a 
sufficient time in the proper position, and a proper walking shoe used 
for a year, a new facet of the astragalus will be formed and a cure 
effected. In a few cases this is not the case, and in such instances os- 
teotomy of the neck of the astragalus suggests itself as a suitable oper- 
ation. 

The procedure will not be found a difficult one. Tenotomy or open 
incision and division of the fascia and ligaments should be clone, and 




FlG. 485. — Same Case Six Weeks After Operation by Forcible Correction. 

the foot stretched and manipulated into as nearly normal a position as 
possible. An incision through the skin is made from the tip of the 
malleolus to the inner side of the head of the first metatarsal, which 
will be found in severe cases close to the malleolus. The incision is 
close to and nearly parallel to the tibialis anticus tendon, and in the 
direction of the metatarsal. The incision should be made to the bone 
and the foot straightened, as the metacarpal bone is separated from the 
malleolus. The scaphoid will be seen before the astragalus is encoun- 
tered, if the deformity is great, and it will be first within the reach of 
the knife in all cases. If the foot is still further stretched, the scaphoid 
begins to uncover the side of the astragalus, and the neck of the astrag- 
alus is seen ; a small osteotome is entered and placed upon the neck of 
the astragalus, to the proximal side of the scaphoid articulation, and the 



542 



ORTHOPEDIC SURGERY. 



neck of the astragalus divided or nearly divided. The foot is then for- 
cibly straightened, and the neck of the astragalus unchiselled is fract- 
ured. The result is similar to that in Macewen's operation for knock- 
knee, and the distortion at the neck of the astragalus is removed. It is 
manifest that the line of section of the bone at the neck of the astraga- 
lus should be transverse to the axis of the bone, and at such a plane 
that when the equinus deformity is corrected the resulting gap at the 
section should not be greater than necessary. The foot should be fixed 
in an overcorrected position. A wedge-shaped resection of the neck of 
the astragalus through a skin incision in the outer and upper surface of 
the foot has been performed, but linear osteotomy 
would seem to be preferable. 

Osteotomy of the Head of the Os Calcis. — The 
relation of the cuboid to the os calcis is frequently 
masked, lying deeper than that of the scaphoid and 
astragalus, and it may in treatment be but par- 
tially corrected. The distortion of the os calcis at 
its anterior aspect, if not corrected, increases and 
forms an obstacle to the complete restoration of 
the cuboid to the normal position, although the 
rest of the deformity may have been corrected. 

When the cuboid is cartilaginous and the liga- 
ments are well stretched, the defect at the anterior 
portion of the os calcis can be overcome by forc- 
ibly correcting the foot and retaining it in the 
corrected position by means of a plaster-of-Paris 
bandage, care being taken, however, that the cuboid 
be restored to place, and in time it will be found 
that the cartilaginous abnormality in the shape of the os calcis is grad- 
ually changed under corrected pressure. 

When distortion of the head of the os calcis is great, no amount of 
mechanical treatment can overcome the obstacle, if it is of bone and if 
the ligaments are strong, binding the bones in a distorted position. It 
is manifest under these circumstances that the rational treatment is a 
removal, not of the astragalus or cuboid, but of a part of the projecting 
portion of the head of the os calcis. 

After complete stretching or division by tenotomy, force, or open 
incision of the contracted tissues on the inner and under side of the 
foot, tendons, ligaments, and fasciae, if it is found that the front of the 
foot cannot be brought to a perfectly corrected or overcorrected posi- 
tion, an incision should be made on the outer side of the foot, passing 
from behind the external malleolus forward and downward. The incis- 
ion should be a curved one, and the chief convexity should be at the 
forward portion of the os calcis. This incision should reach to the 




Fig. 486.— From Photo- 
graph after Removal 
of Astragalus of Left 
Foot for Club-foot. 



TALIPES. 



543 





Fig. 487.— Sole Imprint after Removal of 
Astragalus for Club-foot. 



Fig. 488.— Sole Imprint of Case of Club-foot 
Corrected by Tenotomy, without Contrac- 
tion but with Inversion of the Foot. 



bone and should expose the peroneal tendons. These can either be 
drawn to the side or divided to be stitched later. The upper portion of 
the incision should reach behind the external malleolus, and should ex- 





FlG. 489.— Imprint of Left Foot before Opera- 
tion. 



Fig. 490.— Imprint of Left Foot after Opera- 



544 



ORTHOPEDIC SURGERY. 



tend far enough up to allow sufficient retraction of the flap to give room 
for the osteotomy. After the bone has been reached, and the periosteum 
divided and pushed aside, an osteotome should be inserted far enough 
back to remove a sufficient amount of bone. The direction of the inser- 
tion of the osteotome should be such as to allow the placing of the cu- 
boid, after the bone has been removed, in a normal position. This step 
of the operation requires some nicety and judgment, as it is of impor- 
tance that the front plane of the bone, after the wedge has been re- 




FlG. 491.— Case of Bad Relapsed Congenital Club-foot in a Woman of Thirty-four, Corrected 
by Force with the Use of a Wrench. Photograph taken three months after correction. 



moved, should be in the direction of the normal facet of the front of the 
os calcis. A wedge-shaped portion of bone should be removed from the 
anterior and outer part of the os calcis, and the cartilaginous ends saved 
in order to allow a proper amount of motion between the cuboid and 
the os calcis after recovery. The wedge-shaped portion of bone that 
should be removed should be ample and enough to allow the replace- 
ment of the front of the foot in a normal or overcorrected position 
and the restoration of the proper direction of the os calcis. 

The wound should be carefully washed out to remove any frag- 
ments of bone that may have been left, and subsequently stitched ; the 
tendon of the peroneus longus, if divided, being stitched. The foot 
should then be dressed with proper dressings and fixed in an overcor- 



TALIPES. 



545 



rected position by plaster bandages according to the ordinary rules in 
osteotomy. 

Whether this operation should be clone in connection with an oste- 
otomy of the neck of the astragalus, and with an open incision at the 
same sitting, is a matter of judgment in each case. 

Imperfect results are due to neglect of thorough asepsis, failure to 
remove a sufficient amount of bone, failure to remove it in such a direc- 
tion as to cure the deformity, and lack of care in placing the foot in an 
overcorrected position after operation. 

While the plaster is hardening the cuboid is pressed upward and 
outward, and the front of the foot pressed outward and upward, counter- 




Fig. 492.— Case of Bad Relapsed Congenital Club-foot in a Woman of Thirty-four, Corrected 
by Force with the use of a Wrench. Photograph taken three months after correction, 
showing cicatrix of the tear of the skin caused by correction. (See Fig. 491.) 



pressure being applied on the astragalus on the outer and upper side, 
and the os calcis twisted into its normal position. 

Treatment can be carried out with a plaster-of-Paris bandage until 
the foot is thoroughly healed, and also until locomotion has been re- 
established. After this the use of the club-foot shoe is advisable for 
at least some months. 

Relapses. — No error is greater than a common one, namely, that 
tenotomy alone is sufficient to correct club-foot. In fact, tenotomy is 
only the beginning of a course of treatment. If the foot is rectified 
and held in place for a month, it is supposed by some surgeons that a 
cure has been effected. But such is by no means the case. 
35 



546 ORTHOPEDIC SURGERY. 

Moreover, it must always be borne in mind that relapses will inva- 
riably occur unless the distortion is overcorrected, and little reliance 
can be placed on the curative effect of time. Efforts at correction 
should be continued until the foot can be easily abducted beyond the 
median line, and while slightly abducted, can be flexed so that the dor- 
sum of the foot shall form less than a right angle with the leg, the 
sole of the foot being flat, and there being no twist in the front of the 
foot. After this the correction appliance can be gradually omitted 
while manipulation of the foot is still carried on, and the case should 
be kept under observation. 

Relapses occur in a certain number of cases simply from the care- 
lessness of the parents, who are not aware of the necessity of retaining 
the corrected foot in the proper position for a long time. In such 
cases a second operation is advisable. 

Relapses in older children are due to incomplete correction, either 
from a lack of thoroughness or from the existence of an unusual amount 
of distortion of the astragalus or os calcis not suspected, and demand- 
ing osteotomy, or from too early removal of the fixation or retention 
appliance. 

In some instances of resistant club-foot it is found difficult, in cor- 
recting the foot, completely to overcorrect the equinus deformity, and 
to enable the foot to be brought to within a right angle with the leg. 
If this is not done, inconvenience is felt by the patient in taking a long 
step, and the foot is turned in to facilitate this. The smaller the foot 
the greater this danger. If this is not corrected, it may, in some in- 
stances, seriously interfere with the excellence of the result. 

It should always be borne in mind that a distortion in the neck of 
the astragalus or in the head of the os calcis exists, even in infantile 
club-foot, and that the feet are not permanently corrected until the 
alteration of the facets into a normal position has taken place. This is 
independent of bringing the foot into a normal position, and demands 
fixation in an overcorrected position for some time. In some cases this 
is more needed than in others, probably because the alterations of the 
facets of the. astragalus are in some instances slight. 

Too great overcorrection of the deformity and the development of a 
splay-foot have sometimes resulted from overzealous treatment. The 
danger is, however, not great ; and instances are rare, and are to be 
overcome by the treatment for a valgus foot. 

Inversion of tJic foot, after cure of the club-foot, may in a few in- 
stances be observed from imperfect strength of the outward rotatory 
muscles at the hip. This, however, causes but little disfigurement, the 
inversion usually being slight, and correcting itself by the normal devel- 
opment of the muscles. A marked toeing-in of the foot in running per- 
sists a long time in some instances in which the foot is entirely cor- 



TALIPES. 547 

r'ected and the walking is normal. It disappears with the increase of 
muscular strength. In such cases the ordinary Taylor shoe should be 
carried up to the hip by means of an upright on the outside of the leg 
and a posterior arm carried back from the level of the trochanter, as in 
the knock-knee splint. By tightening this, eversion is secured. 

A relaxed state of the knee-joint causing inversion of the tibia is not 
uncommon in infantile club-foot ; it usually corrects itself in the devel- 
opment of the child after correction of the foot. In rare instances, 
however, it may persist, requiring the longer use of a walking appliance. 

The muscles retarded in club-feet by disuse need development be- 
fore a complete cure is effected. Ordinarily the muscles develop of 
themselves after complete correction, if the limbs are actively used. In 
some cases the development is slow and massage and electricity are 
advisable. 

Generalization as to Treatment. — The literature of the treat- 
ment of club-foot is too often that of unvarying success. It is some- 
times as brilliant as an advertising sheet, and yet in practice there is no 
lack of half -cured or relapsed cases — sufficient evidence that methods of 
cure are not universally understood. 

Surgeons differ somewhat in regard to the method of treatment of 
club-foot, but the following statements are regarded by the writers as 
worthy of acceptance : 

First — It is possible to correct completely infantile cases of con- 
genital club-feet without the help of any operative interference, even 
tenotomy. 

Second. — Tenotomy, however, even in infants is of assistance, and in 
older cases is in almost all instances necessary for a perfect cure. Te- 
notomy properly done is not followed by any unfavorable results to the 
muscles. 

Third. — Certain resistant cases can be corrected and cured without 
operation upon the bone, but in such cases considerable force must be 
used. 

Fourth. — In resistant cases, however, when there is deformity of the 
bone, osteotomy or a wedge-shaped resection of the astragalus or os 
calcis is necessary. 

Fifth. — Congenital club-foot is a thoroughly curable deformity, pro- 
vided the pathological conditions existing are thoroughly understood, 
and the resisting structures overcome. 

Sixth. — For cure, overcorrection of the deformity is necessary and 
retention in an overcorrected position until the normal relation of the 
parts has been established. 

Seventh. — The best retention appliance is one which interferes with 
the normal motion the least without permitting the distorted position 
of the foot. 



54§ ORTHOPEDIC SURGERY. 

Acquired Club-Foot — Paralytic Deformity. 

The most common form of acquired talipes eqmno-varus is that fol- 
lowing infantile paralysis which is described in another chapter. 

The prognosis of paralytic club-foot is necessarily more unfavorable 
than that of the congenital form, although the distortion is more readily 
corrected; it is impossible to restore the affected muscles to a normal 
condition, and the prolonged use of some form of appliance may be 
necessary. In some instances, however, after thorough correction and 
retention for a while in a corrected position, if the foot is of sufficient 
size, relapse does not take place, or does so only in a partial degree, and 
a useful and but slightly distorted foot remains. 

The correction of paralytic club-foot is to be conducted on the same 
principles as that of the congenital type. Correction is, however, much 
less difficult, as osseous changes are present only in the old severe and 
neglected cases. 

Tenotomy of the contracted and healthy muscles can be done as in 
congenital cases, though overcorrection after tenotomy is to be avoided. 
Immediate correction and fixation in a corrected position are to be used 
after tenotomy as in the congenital form. 

Tendon transference and arthrodesis as applied to this affection are 
discussed under infantile paralysis. 

The walking appliance to be used in paralytic cases is in general the 
same as that which has been described in congenital cases. 

TALIPES EQUINUS. 

(Pes equinus, Horse heel, Pied bot equin, Pferdefuss, and Spitzfuss.) 

Talipes equinus is the name given to a condition in which the foot is 
held in a position of plantar flexion and cannot be dorsally flexed to the 
normal extent (twenty degrees beyond a right angle). 

Varieties. — Talipes equinus may be congenital or acquired. Con- 
genital equinus is an uncommon deformity, constituting about five per 
cent of all cases of equinus. In 1,660 congenital deformities of the 
foot there were 40 cases of equinus. Its origin is no more clear than 
that of other similar congenital deformities. The congenital form of 
the deformity is generally not severe. 

Acquired Talipes Equinus. 

In the acquired forms all degrees of deformity are met, from the 
slight condition in which the foot cannot be flexed dorsally beyond a 
right angle with the leg, to one in which the foot and leg form practi- 
cally a straight line. 



TALIPES. 



549 



Etiology. — The causes of acquired talipes equinus are as follows: 
i. Infantile paralysis of the anterior muscles of the leg. 

2. Cerebral <; spastic) paralysis, hemiplegia, pseudo-hypertrophic 
paralysis, neuritis, and similar affections causing either loss of power in 
the anterior muscles of the leg or an overbalancing of these muscles by 
the contraction of the posterior group. 

3. Shortening of the leg after joint disease or fracture may lead to 





Fig. 493. — Talipes Equinus of Marked 
Degree. This represents the 
weight-bearing position. 



Fig. 494. — Talipes Equinus of Left Foot Resulting 
from Paralvsis. 



an adaptive talipes equinus which serves to make the legs of equal 
length for walking. 

4. Talipes equinus may be a symptom or result of disease of the 
ankle-joint. 

5. Long confinement to bed may cause talipes equinus, which is 
merely the result of the long-continued plantar flexion of the foot. 

6. Fractures may result in talipes equinus either from injury to the 
ankle-joint or from fixation during repair in a plantar-flexed position. 



5 SO ORTHOPEDIC SURGERY. 

J. Hysteria may be a cause. 

8. The contraction caused by posterior cicatrices or the loss of power 
due to division or injury of the anterior muscles and tendons of the leg 
may cause the deformity. 

Pathology. — The structural changes in talipes equinus are slight. 
In a large number there is simply a shortening in the Achilles tendon 
or muscles, with a consequent alteration in the shape or relation of the 
bones and soft tissues of the foot. Some cases, however, are due less 
to the raising of the calcaneum than to a depression of the head of the 
astragalus, which may be depressed nearly in a vertical line, and the 
arch of the foot increased by a strong flexion at the medio-tarsal joint. 

Symptoms. — The deformity in its slighter degrees is not particularly 
disabling. In its severer grades it is the cause of a severe limp and at 
times of much discomfort. A slight degree of the affection may be 
enough to cause a limp in walking, as in carrying the leg back at the 
end of the step the foot should be bent to more than a right angle. 
Corns and calluses of a severe grade are frequently found on the sole 
at the front of the foot. They may be a source of severe discomfort. 
In cases of moderate severity the weight of the body is borne on the 
distal end of the metatarsals in walking, the toes being hyperextended. 
In the severest forms of all the foot is bent on itself, so that the sole is 
directed backward and locomotion takes place on the dorsal surface of 
the metatarsus and toes. The arch of the foot is generally higher than 
the normal, and the condition which will be described as pes cavus may 
coexist with the equinus. 

In the severer forms there is a marked projection on the dorsum of 
the foot formed at the site of the calcaneo-cuboid and astragalo-scaph- 
oid articulations. As locomotion occurs only on the ball of the foot, 
this part becomes abnormally wide, and in time the plantar fascia con- 
tracts and resists the reduction of the malposition. 

The spastic form is most commonly met in spastic paralysis or after 
hemiplegia. As this is due to the contraction of the muscles of the 
tenclo Achillis, the position of the foot in this differs from that follow- 
ing paralysis. The heel, in the spasmodic form, is drawn upward and 
the whole foot depressed in consequence. There is, therefore, less ten- 
dency to the formation of an angle in the medio-tarsal or tarso-metatar- 
sal joints. 

The form often met in shortened limbs, as after recovering from hip 
disease, fracture, etc., is the result of the maintenance of the foot for a 
long time in a partially extended position, in the act of walking and 
standing. In these cases it is a compensatory arrangement, inasmuch 
as it tends to keep the pelvis level, and not to be regarded as objection- 
able except in its appearance. 

The detection of talipes equinus is a simple matter. The normal 



TALIPES. 5 5 I 

foot should be capable of flexion about twenty degrees beyond a right 
angle, and any cause which restricts this flexion is a degree of talipes 
equinus. 

Treatment. — The division of the tendo Achillis will relieve the de- 
formity in all cases except those in which bony deformity exists at the 
ankle, as in the cases following fracture and tuberculosis of the ankle- 
joint. In such cases or in extremely severe instances of deformity 
from other causes, a wedge-shaped osteotomy of the tarsus might be 
required for rectification, but this would be unusual. 

The deformity should be at once corrected after tenotomy and a 
plaster-of- Paris bandage applied. If a retention appliance is required 
after operation, a modification of the club-foot shoe, with the ankle-joint 
arranged to stop extension at a right angle, w r ill be found to be effect- 
ual and simple. Or a simple foot-piece joined to two uprights and a 
posterior band ma) 7 be used, which is jointed in the same way at the 
ankle. This prevents the foot from rolling in or out and thus makes 
the act of walking a force to pull upon the tendo Achillis at each step 
(Chapter XXL. £8). 

Acquired talipes equinus is in most cases due to anterior poliomye- 
litis, and the treatment of that form has been discussed there. In 
cases due to ankylosis of the ankle-joint or to severe acquired distortion 
of the bone from prolonged neglect, a wedge-shaped osteotomy might 
be necessary. 

TALIPES CALCANEUS. 
(Pes calcaneus, Pied bot calcaneen, and Hackenfuss.) 

Talipes calcaneus is the name applied to a condition in which the 
foot is held in a position of dorsal flexion. 

Varieties.— The deformity may be congenital or acquired. 

It is a comparatively rare congenital deformity, about two-thirds as 
common as congenital equinus (28 cases in 1,660 cases of congenital 
deformity of the foot). The hollow in the sole of the foot so often 
present in the acquired variety is likely to be absent in the congenital. 
It may be noticed only as a slight downward prominence of the heel or 
it may be so se ere that the dorsum of the foot may be laid against the 
anterior surface of the tibia. Its etiology is practically the same as 
that of the other congenital deformities. 

Acquired talipes calcaneus is less common than acquired equinus. 
It presents the same characteristics as the congenital form, except that 
an increased hollowness in the arch of the foot is likely to coexist, in 
which case the deformity may be spoken of as talipes calcaneo-cavus. 
The cause of the acquired deformity is in most cases paralysis of the 
muscles of the calf of the leg from anterior poliomyelitis. It may occur 
in chronic disease of the ankle as a symptom of muscular irritability. 



552 



ORTHOPEDIC SURGERY. 



It exists sometimes in hysteria, and it may result from rupture or divis- 
ion of the posterior muscles of the leg, from cicatrices in the front of 
the ankle, and from ankylosis of the ankle-joint in a faulty position. 

The pathology of the affection is manifested by the changes incident 
to the maintenance and use of the foot in this abnormal position. 
Stretching of ligaments and muscles are found on one side, with short- 
ening on the other and changed relations between the bones, resulting 
perhaps in the development of new articular facets. 

Symptoms. — The patient walks upon the heel and the gait is inelas- 
tic, because the spring of the foot is absent and the patient walks bear- 




FlG. 



-Talipes Calcaneus. 



ing the whole weight on the os calcis. The diagnosis presents no diffi- 
culty, except that it must be remembered that the association of the 
deformity with both valgus and cavus is frequent. 

Treatment. — In congenital cases the foot should be daily manipu- 
lated by the parents into a position of plantar flexion. As soon as the 
anterior muscles are stretched, it is advisable to put the foot up in a 
position of plantar flexion, to bring about adaptive shortening of the 
posterior muscles. In the severer cases the application of a series of 
corrective plaster bandages holding the foot in plantar flexion may be 
necessary. Tenotomy of the anterior tendons is rarely required. 
When the foot can be plantar-flexed to the normal amount, a retention 
shoe preventing dorsal flexion may be applied, but in slight cases this 
is not necessary (Chapter XXL, 29). 



TALIPES VALGUS. 



Talipes valgus is the name given to a condition which is not in all 
cases to be clearly differentiated from what has been described as flat- 



TALIPES. 



553 



foot. Talipes valgus may be congenital or acquired. As a congenital 
deformity it is one of the more common of the congenital deformities of 
the foot. In 1,660 cases of congenital deformity of the foot there were 
123 of congenital valgus. The bones in congenital flat-foot even in 
severe cases show but little alteration in shape. The astragalus is 
turned obliquely to one side and downward, and the angle of the artic- 
ulation faces more to the side than 
is normal. The end of the os calcis 
may be slightly raised. The sca- 
phoid is turned to the outer side 
and is rotated on its central axis, so 
that the outer side is slightly raised 
and the inner side is lowered — the 




FIG. 496.— Moderate Degree of Talipes 
Valgus, Right Foot. 




FIG. 497.— Talipes Varus, Right Foot. 



arch of the foot is obliterated and the inner border is often convex 
rather than concave. 

It may exist by itself or in connection with other defects of the 
bones of the foot or leg. It may exist alone or associated with calca- 
neus or equinus. The deformity of congenital valgus is likely to be 
extreme and the sole of the foot may present a downward convexity. 
The three elements mentioned in flat-foot — abduction of the front 
of the foot, eversion of the sole, and lowering of the arch — may 
be fully developed. The changes of the bones do not differ essen- 
tially from those described in acquired flat-foot. The deformity may 



5 54 ORTHOPEDIC SURGERY. 

be spoken of as congenital flat-foot, from which it is not to be dis- 
tinguished. 

Acquired Talipes Valgus is a condition characterized by eversion of 
the sole of the foot or abduction of the front of the foot in relation to 
its long axis, or by both. It differs from acquired flat-foot in the ab- 
sence of a distinct dropping of the arch of the foot. This distinction 
is not to be made in all cases nor is it of great importance, but, in gen- 
eral, cases presenting the two first conditions mentioned are to be 
classed as valgus, and cases with the dropping of the arch also as flat- 
foot. The most common cause of acquired talipes valgus is anterior 
poliomyelitis. It also occurs in hysteria, following inflammation of the 
ankle-joint, and in certain cases of spasm of the peroneal muscles. 
The symptoms, as contrasted with those of flat-foot, are generally char- 
acterized by less pain, and the modification in the gait produced by the 
abnormal position is in general more prominent than pain. 

The treatment of the condition consists in the application of an ap- 
paratus (Chapter XXI., 31) to correct the rolling inward of the ankle, 
combined generally with some support to the arch of the foot. In the 
milder cases the application of a flat-foot plate would be sufficient treat- 
ment. 

TALIPES VARUS. 

Talipes varus is the name given, to a condition in which the soleiof 
the foot is turned inward. Simple talipes varus occurred eighty-fwe 
times in sixteen hundred and sixty congenital deformities of the foot. 
In its congenital form the deformity is apparently an incomplete vari- 
ety of ordinary club-foot in which the element of equinus is not marked. 
In the acquired form it results from infantile paralysis and is at times 
seen as the result of severe knock-knee. As associated with talipes 
equinus it is the commonest of congenital deformities of the foot. 

Treatment. — In the congenital form the treatment is practically the 
same as that of equino-varus, except that it may not be necessary to 
cut the tendo Achillis. In the acquired form retentive apparatus is 
useful, preventing eversion of the foot (Chapter XXI., 30). 

TALIPES CAVUS. 

(Hollow foot, Pes cavus, Pes arcuatus or excavatus, Pied bot talus, 

Pied creux, Hohlfuss.) 

Talipes cavus is the name given to a condition in which the arch of 
the foot is increased and the anterior part of the foot is approximated 
to the heel. It is not necessarily associated with any other deformity, 
but may occur in connection with talipes equinus, calcaneus, valgus or 



TALIPES. 



55 



varus. It is rarely congenital in its severe forms, 1 but a markedly 
high arch to the foot may be an inherited peculiarity sometimes suf- 
ficiently marked to justify classing it as pathological. In the acquired 
form it exists in most cases as the result of anterior poliomyelitis, 
and is also to be classed as a shoe deformity. The pathological 
changes show nothing besides the effects of a continued malposition 
of the bones. The deformity varies more or less in degree. The most 
marked form is to be found in the foot of the Chinese lady of high rank, 
in which the heel and front of the foot are approximated by bandaging 
in early youth, and a degree of pes cavus is induced which does not 
exist except under these highly artificial conditions. From this ex- 




FlG. 49S. — Pes Cavus with an Element of Calcaneus. 

treme grade all degrees of the affection are seen, the slightest being an 
increased elevation of the arch not accompanied by symptoms, in which 
the foot rests upon the ground in standing, touching only on the heel 
and ball of the foot. It is less disabling than pes calcaneus, and is fre- 
quently associated with the other deformities mentioned. The two 
types commonly seen are, first, those resulting from anterior poliomye- 
litis, in which a paralysis more or less extensive has involved the foot 
and leg. In a second form, generally milder in grade, it apparently de- 
velops as a shoe deformity in middle childhood, and appears to be the 
result of wearing too short a shoe or of a shoe narrower than the front 
1 Redard : " Chir. orth.," p. S39. 



556 ORTHOPEDIC SURGERY. 

of the foot ; the front of the foot being held back by the front of the 
boot, the tendency in weight-bearing is to approximate the heel and the 
toe, and in this way to approximate the front of the foot to the heel. 
In the slightest grade it apparently forms one of the varieties of the 
condition described as contracted foot. The plantar fascia is contracted 
and bands may be felt under the skin., The symptoms in the slighter 
varieties are those of a sprain of the arch of the foot and the muscles of 
the leg, owing to insecure balance of the foot in standing. Corns and 
callosities may develop in the front of the foot ; the elasticity of the 
gait is impaired. 

The treatment of the slighter forms, in which the symptoms are 
due to the imperfect balance of the foot, consists in the use of a boot 
with sufficient room in front and of proper length, which is provided 
with a high arch or artificially high shank, to give the foot a correct 
bearing surface and to contribute to its stability. If any element of 
equinus coexist, the gastrocnemius muscle must be stretched. 1 In 
cases of average severity in young children a flat steel plate running 
the length of the boot may be inserted between the layers of the sole, 
and the dorsum of the foot strapped down to it by a strap running over 
the top of the foot and fastening to the plate. This will tend to stretch 
the contracted tissues in walking. Operation is required in the severer 
cases. The plantar fascia is thoroughly divided by a subcutaneous te- 
notomy and the foot put up in a plaster bandage which should flatten 
the arch of the foot as much as possible. When walking is begun, 
which should be as early as possible after operation, the steel sole plate 
and strap described above should be adjusted to the shoe. 

CLUB-HAND. 

In German the distortion is known as Klumphand, and in French 
as main bote. 

Congenital club-hand is a rare condition, which is in many cases 
analogous to congenital club-foot. The name is applied to a deviation 
of the hand, at the wrist, from the line of the forearm ; this deviation 
is almost always in the direction of flexion. 

It occurs at times without malformation of bones, in which cases 
there may be also stiffness of the shoulder- and elbow-joints of the 
affected arms, with imperfect development of the muscles. At other 
times there is associated with the club-hand an absence or defective 
development of the radius or ulna, often associated with other malfor- 
mations. With the defective development of the bones of the forearm 
are likely to be associated muscular defects and anomalies. 

Varieties. — The modern classification of the distortion is to speak 
of the cases as palmar and dorsal club-hand, as the deformity is toward 
1 Shaffer: N. Y. Med. Jour., March 5th, 1887. 



TALIPES. 



557 



flexion or extension ; or as radial, and ulnar or cubital, as the deviation 
is inward or outward at the wrist. Mixed forms are the most common, 
and are spoken of as radio-palmar, etc. The dorsal forms are rare. 
The bones of the arm may be normal, but more commonly they are 
deformed, or the radius may be wanting wholly or in part. The carpus 
may be normal, or incompletely developed, or almost entirely wanting. 
When the radius is deficient, the lower end of the ulna is enlarged to 




FIG. 499. — Club-hand Due to Congenital Absence of Radius. (Sayre.) 

articulate with the carpus. A variety of anomalies of the muscles, ves- 
sels, and nerves may occur. 

Etiology. — No satisfactory etiological cause can be assigned for the 
occurrence of club-hand, beyond the usual explanations urged to ac- 
count for congenital deformities in general. 

Symptoms. — In looking at the palmar varieties of club-hand it is 
seen that the wrist is sharply flexed, and that perhaps the lower end of 
the radius may be covered by the skin and traversed by the extensor 
tendons, while the carpus articulates with the under surface of the 
radius. The forearm is wasted, and if the radius is absent it appears to 
be very slender indeed. The hand possesses a certain degree of mobil- 
ity at the wrist, and when it is partly replaced the flexor tendons can be 
felt to be rendered tense, and stand out under the skin. 



558 ORTHOPEDIC SURGERY. 

The diagnosis is evident, and any pathological process which is ac- 
companied by this malposition is classified as club-hand. 

Treatment. — In the mildest cases, particularly if the bony structure 
is normal, treatment should consist of manipulation to stretch the con- 
tracted tissues and retention in the correct position by means of a 
splint. 

Tenotomy is to be clone only if reposition is impossible without it. 
After retention in the proper position for a sufficient time, massage and 
muscle training should be begun. 

Where bony defects are present and the case is not to be rectified 
by the measures described, some operation on the bone may be per- 
formed. R. H. Sayre ' performed an osteotomy of the ulna to correct 
its curve, and later removed two of the carpal bones and the styloid 
process of the ulna and inserted the end of the ulna into the gap in 
the carpus. Thompson 2 removed a wedge from the lower part of the 
ulna. McCurdy divided the ulna across and sutured the distal end to 
the semilunar bone. 3 Bardenheuer ' has split the lower end of the ulna 
longitudinally and implanted the carpus between the two parts of the 
ulna separated. 

The reported results of these operations have been favorable, but it 
must be evident that the joint under these conditions must be an im- 
perfect one. 5 

'Trans. Am. Orth. Assn., vol. vi., p. 208. 

"Ibid., vol. ix., p. 165. 

z Ibid., vol. viii.; p. 8. 

4 Verhandlung der deutschen Gesellschaft f . Chir.. 1894. 

£ Kirmisson: "Mai. Clin. d'Origine Congen ," 1898. 



CHAPTER XX 



FLAT-FOOT AND OTHER DEFORMITIES 

FOOT. 



OF THE 



Flat-foot (Definition. — Pathology. — Varieties. — Causation.- — frequency. — Symp- 
toms. — Diagnosis. — Prognosis. — Treatment). — Anterior metatarsalgia. — Hal- 
lux valgus. — Hallux varus. — Hallux rigidus. — Hammer toe. --Clawed toes. — 
Painful heel. — Post-calcaneal bursitis. — Synovitis of tendo Achillis. — Exos- 
toses. 

FLAT-FOOT. 

Definition. — The term "flat-foot" is applied to a deformity usually 
of a static type — that is, one due to superimposed weight. This deform- 





Fig. 500.— Print of Child's Foot in Mocca- 
sin, Showing Weight- bearing Portion of 
Foot. 



FIG. 501.— Foot of Japanese Bronze. 
(Boston Art Museum.) 



ity resembles in many respects talipes valgus, and has been consid- 
ered by many writers a variety of that distortion. There is, however, 
sufficient difference to warrant a consideration of flat-foot by itself. 

559 



560 



ORTHOPEDIC SURGERY 



The abnormality of flat-foot is best understood by a comparison with 
the normal standard. 

Normal Foot.— If the foot of a young infant is examined it will be 




Fig. 502.— Feet of Charioteer, 



FIG. 503. — Egyptian Statue. 



seen that there is muscular power in the movement of all of the toes. 
The great toe can voluntarily be drawn to the inner side, and the fifth 



FLAT-FOOT AND OTHER DEFORMITIES. 561 

toe can be drawn to the outer side by voluntary muscular exertion. 
The toes can be flexed readily. The second toe is, when stretched to 
its full length, frequently longer than the first. The third is of the 
same length as the first, the fourth is somewhat shorter, and the fifth, 
though shorter, is but slightly so. None of the toes remains perma- 
nently curled, though when in a relaxed condition the terminal phalanx 
drops somewhat and the smaller toes curl. A separation between the 
first and second toe is normal. When the muscles are active the great 
toe is drawn to the inner side frequently. The line of the extremities 
of the toes presents a gradual curve with the greatest forward con- 
vexity at the tip of the second toe. The line of the inner edge of the 
foot is always straight except when there is contraction of the muscles. 




Fig. 504.— Left Foot of Child Eighteen Mouths Old. (Dane.) 

If the undistorted adult foot which has never worn shoes be exam- 
ined, it will be found to present many of the characteristics of the 
infant's foot, but there is greater muscular power in the toes and foot 
and relatively less fatty tissue. The flexibility of the front of the foot 
is great, and can be increased by training, especially in the power of 
separating the great toe from the next, which is utilized as an aid in 
prehensibility. 

If in comparison the foot of an adult who has always worn shoes is 
studied, a loss of flexibility in the movements of the toes, often some 
distortion of the front of the foot, and an impairment of muscular power 
of the muscles of the foot are seen. The effect of this impairment is 
to favor the development of the deformity generally known as flat-foot. 

Pathology. — In light cases of flat-foot the anatomical changes show 
very few alterations in the shape of the bones. There is simply an 
altered relative position. 1 

1<4 Statik und Mechanik des menschl. Fusses," Zeit. f. orth. Chir., 1894, iii., 
243. — R. W. Lovett and F. J. Cotton: Trans. Am. Orth. Assn., vol. xi.— Peter- 
sen : Arch. f. Orth. (abst.), i., 3.— Riedinger : Centralbl. f. Chir., 1897, No. 15.— v. 
Meyer : " Ursache und Mechanismus der Entstehung des erworbenen Plattfusses," 
Jena, 1883. 

36 



562 



ORTHOPEDIC SURGERY. 



The nature of the mechanism of the deformity will be better under- 
stood if the normal action of the foot in standing and walking is borne 




Fig. 505. — Savage Feet. 

in mind. If an individual with normal feet stands with both feet 
placed together and pointed forward, the weight in each foot falls upon 
a point midway between the outer and inner edge, passing through the 



FLAT-FOOT AXD OTHER DEFORMITIES. 



163 



ankle and astragalus and being distributed to the rest of the foot. If, 
now, the superimposed weight is made excessive by having the individ- 
ual stand upon one foot, the body inclines to that side to preserve the 




1 



^1 



Fig. 506. — Longitudinal Section of Foot. (Fick.) 

balance and to prevent side strain. When the weight upon the foot 
comes in such a way that it cannot be brought directly over the middle 
of the foot, a movement takes place whereby the side strain is dimin- 
ished. This represents the position of muscular strength when exposed 
to the strain of excessive superimposed weight. In this movement the 



564 



ORTHOPEDIC SURGERY 



astragalus and ankle are pulled sideways to the outer side of the foot, 
the ball of the foot and the heel being placed firmly on the ground and 
the astragalus being held firmly from lateral motion by the tibia and 
the fibula. This motion, which is made possible by the many articu- 
lations of the foot, occurs in the midtarsal joint chiefly. The scaphoid, 
the inner cuneiform, and the posterior end of the first metatarsal are 




Fig. 



-Posterior View of Foot, Showing Ligamentous Support and its Weakness to 
Strain Inward. (Fick.) 



brought upward and to the outer side, the great toe and the head of the 
first metatarsal are pressed firmly on the ground, and the os calcis and 
the cuboid move with the astragalus. 

In contrast with this movement of strength and muscular support 
must now be considered the position of 'relaxation and ineffectual sup- 
port. When the patient is standing, if the muscles moving the great 
toe and the head of the first metatarsal or those regulating the outward 
and upward movement of the inner side of the scaphoid are weak or 



FLAT-FOOT AND OTHER DEFORMITIES. 



565 



inefficient or do not act with strength, the midtarsus drops to the inside 
when superimposed weight falls upon it, and the movement is the re- 
verse of that described above. The astragalus rotates inward; the 
scaphoid, the cuneiform, and the proximal end of the first metatarsal 
move downward and inward ; and the front end of the os calcis and the 
cuboid follow the astragalus to the side. This involves a twisting of 
the whole limb, which rotates at the hip-joint. The astragalus moving 
with the leg on the bones of the foot, the inner malleolus will in conse- 
quence be seen to move downward, inward, and backward. Up to a 
certain limit this movement occurs in relatively normal feet, but be- 





FlG. 508.— Pr.'nt of Arab Foot. 



Fig. 509.— Plaster Cast of Dental Wax Foot 
Impression in Sand, Showing Weight- 
bearing Portions of Foot. 



yond this what must be regarded as a pathological condition is reached, 
attended by symptoms of pain and disability, and is the first step in the 
formation of flat-foot. 

The deformity, strictly speaking, is not a flattening of the foot, but 
consists of an exaggerated midtarsal drop and twist, occurring, as has 
been said, normally under certain conditions. The deformity is a com- 
bination of inward rolling and dropping to the inside of the middle of 
the foot, with an outward deviation of the front of the foot. Normally 
in the standing position, if the patella faces straight to the front, the 
foot should be directed also straight ahead ; but in flat-foot the front of 
the foot turns to the outside when the leg is placed with the patella 



566 



ORTHOPEDIC SURGERY. 



and ankle squarely to the front. The deformity has for this reason 
been termed pronated foot, as the deformity somewhat resembles pro- 
nation. It is also called weak or weakened foot. 




FIG. 510. — Casts of Civilized and of Savage Feet. 

There is necessarily a variation in the relative prominence of the 
different factors of the deformity in individual feet: 1. The inward 




fT" "" 




FlG. 511.— Voluntary Plantar Flexion (Nor- 
mal). (Whitman.) 



Fig. 512.— Voluntary Dorsal Flexion (Nor- 
mal). (Whitman.) 



movement of the midtarsus, "the dropping in " of the foot, may be the 
characteristic of some cases. 2. The dropping down of the arch may 



FLAT-FOOT AND OTHER DEFORMITIES. 



567 



be the most prominent feature in others. 3. The abduction of the 
front of the foot, resulting in a change of the angle between the front 
of the foot and the axis of the heel, may characterize still other cases. 
And these three factors ma}' be present in varying proportions and 




Fig. 513.— Weakened Foot without Breaking- Down of Arch. 

relations. The recognition of the relative prominence of these elements 
is of much importance in treatment. 

Alterations in the shape of the bones are noted, in severe cases the 





FIG. 514. — Meyer's Line in Average Foot. 



Fig. 515. — Meyer's Line in Normal Foot. 



external malleolus being at times somewhat flattened and rounded. 
The chief distortion in the bones occurs in the astragalus, os calcis, 
scaphoid, and cuboid. In extreme cases the astragalus has dropped 
from above to the inside of the os calcis, the latter being rolled to the 



568 



ORTHOPEDIC SURGERY. 



inside with a deviation of its forward end to the inside. The front of 
the foot is turned outward, the scaphoid and cuboid being practically 




.blG. 516.— Table with Glass Top for Examining Feet. 




Fig. 517.— Glass Table for Examining, in Use with Mirror. 

dislocated. At the outer side the cuboid may be displaced upward. 
Changes in the direction of the metatarsus and of the phalanges are 
found. Exostoses are frequently developed. 

There is a loss of the normal play of the bones in the tarsal articu- 



FLAT-FOOT AND OTHER DEFORMITIES. 569 

lations from loss of elasticity of the ligaments, and changes in the 
shape of the bones result from abnormal pressure. 

The muscles are changed in their strength, the tibialis being weak- 
ened and the peronei contracted. 

The plantar ligaments are stretched and displaced, and those bear- 
ing strain are thickened. 

Varieties. — As has been already mentioned, talipes valgus resem- 
bles flat-foot, and they are often classed together. For clinical rea- 




FlG. 51S. — Type of Tracing Described as Normal. 

sons it is more convenient to consider the subjects separately. The 
same is also true of congenital valgus, sometimes called congenital flat- 
foot. 

Infants were thought to be flat-footed, but this has been shown to 
be apparent rather than real. 1 

Causation. — In general terms it may be said that the deformity is 
caused by a disproportion between the weight to be borne and the mus- 
cular power which bears it. Among the determining causes may be 
mentioned : 

1. Boots of improper shape or size. 

2. Weakness or insufficiency of the muscles, resulting from ill 
health and especially following confinement. 

1 Dane: Trans. Am. Orthop Assn . 1898. — Spitzy : Zeitschrift f. orth. Chir., 
xii., 4, 777. 



570 



ORTHOPEDIC SURGERY 



3. Prolonged standing. 

4. Rapid growth. 

5. Rapid increase in weight. 

6. Accident or disease, causing disuse of limb and muscular weakness. 




Fig. 519. — Flat-foot Occurring in a Young- Rhachitic Child. 

7. Excessive weight-bearing, as in the case of professional strong 
men and jumpers. 

8. A shortened condition of the gastrocnemius muscle, as described 





FIG. 520.— Outline Drawing (from Photo- 
graph), Showing Inward Excursion of 
Internal Malleolus in Prona'ion. 



FlG. 521. — Composite Photograph, Showing 
Excursion of Malleolus and Arch with and 
without W T eight- bearing. (C>ane.) 



by Shaffer. Unless dorsal flexion of the foot beyond a right angle is 
possible, it is difficult for a person to complete the step with the leg 
straight behind him and the foot pointing forward. Eversion of the 



FLAT-FOOT AND OTHER DEFORMITIES. 



5/i 



foot is necessary, and a completion of the step by rolling over on to the 
inner side of the foot. 

9. Rickets, distorting the bones of the foot. 

10. Infantile paralysis. 

11. Spastic paralysis or other disturbances of muscular balance. 

12. Trauma and inflammation. 

The most common of traumatic causes is Pott's fracture, in which a 
deformity is the result of inefficient treatment or of a very severe and 
intractable fracture. As a result 
of ankle-joint disease accompa- 
nied by considerable destruction 
of tissue, one sometimes sees 
very marked flat-foot, which does 
not tend to grow worse, because 
there is generally firm ankylosis 
in the ankle; but the deformity 
may be severe. Acute arthri- 
tis, especially of gonorrheal 
origin, is a not infrequent cause 
of flat-foot. 

Causation.— Flat-foot has 
been mentioned as a race pecu- 
liarity, negroes and Jews being 
mentioned as especially afflicted ; 
but facts do not warrant the 
statement, which has been found 
not to be true of the native 
negroes of Africa. 1 

Many of the barefooted races 
have been considered flat-footed 
simply because of the strong 
development of the muscles of 
the sole, careful examination 
showing excellent arches. 

The most common cause is the 
weakening of the muscles of the 

foot by shoes. Shoes as worn by the leisure class or by the class that 
gain their livelihood (as is the rule in cities) by occupations which re- 
quire standing rather than strong and vigorous walking, compress the 
front of the foot. This part of the foot, from compression and from 
resulting weakness, cannot adapt itself as greater weight is thrown 
upon the foot, and the medio-tarsal twisting takes place, which in the 
strong bare foot is prevented chiefly by the action of the tibial muscles 
1 Freiberg: Am. Joura. of Orth. Surgery, vol. i. 




FlG. 522. — Composite Photograph, Showing 
Lateral Excursion of Lower Leg and Foot 

with and without Weight-bearing. (Dane.) 



57 2 ORTHOPEDIC SURGERY. 

and by the muscles of the first metatarsal and its phalanges. People 
the front of whose feet has been compressed stand and walk with a 
greater angle of divergence of the axes of the feet, which increases the 
danger of the development of the deformity by bringing greater strain 
upon the inner side of the foot and favoring the inward rolling which 
frequently develops flat-foot. Flat-foot is not developed among moc- 
casined savages who use their feet actively as hunters, using the mus- 
cles of the front of the foot freely. 

Symptoms. — Flat-foot is a deformity characterized by a flattened 
appearance of the sole of the foot. 

The deformity is also called splay-foot, pes planus, and spurious val- 




FlG. 523. — Tracing of a " Flat-foot. 1 ' No symptoms. 

gus; in German, Plattfuss; and in French, pied plat. It is also some- 
times called pes pronatus. 

It can for convenience clinically be divided into two groups: 

1. Flexible flat-foot or weakened foot, where little or no structural 
changes have taken place and the foot assumes the flattened position 
only when weight falls upon it. 

2. Rigid flat foot or flat-foot proper, in which the distortion is per- 
manent, some structural change in ligament or bone having taken place. 

In Blodgett's ! series of one thousand cases the females predomi- 
nated, and two-thirds of the cases were under forty years of age. 
1 W. E. Blodgett: Am. Journ. of Orth. Surgery, vol. ii., No. 2. 



FLAT-FOOT AND OTHER DEFORMITIES. 5/3 

Deformity. — In the severer cases, instead of the normal arching 
upward of the inner border of the foot, this border is either less arched 
than normal or is in contact with the ground. The foot has the appear- 
ance of being not only broad but abnormally long. It is more or less 
everted, and in severe cases the head of the astragalus and the scaphoid 
tubercle form a marked bony prominence at the middle of the inner 
border of the foot. The internal malleolus is more prominent than 
normal and is thought by the patient to have enlarged. In the milder 
cases, which are often too slight properly to deserve the name flat-foot, 
there is the beginning of a similar process. This beginning abnormal- 





FlG. 524. — Flat-foot of Moderate Degree. 

ity of position, although sufficient to cause symptoms, may be so slight 
as to escape observation except on the closest inspection. There is a 
tendency of the inner malleolus to be more prominent, the foot is 
slightly everted, the weight is borne more on the inner border than 
is normal, and the arch of the foot may appear to be somewhat lower 
than normal. This condition might perhaps be better spoken of as a 
strained than as a flattened foot; from this condition to that of a com- 
pletely flattened foot every degree is to be seen clinically. Marked 
flat-foot may be present without causing symptoms. It is not infre- 
quently seen in athletes and occurs as a perfectly useful foot m a cer- 



574 



ORTHOPEDIC SURGERY. 



tain small proportion of persons. In such cases the foot is flexible; 
when structural changes have taken place in the ligaments, muscles, or 
bones, and stiffness is present, painful symptoms are generally seen. 
Flat-foot is more frequently double than single, and as a rule the 




FIG. 525.— Severe Double Flat-foot. 



symptoms in one foot are more severe than those in the other. The 

symptoms are frequently worse in the foot showing the least deformity. 

Pain. — The first symptom complained of is a sense of discomfort in 

the feet after standing or walking. This may increase until pain of 

greater or less extent is present during 
and following use of the feet. In the 
milder cases pain ceases when the weight 
is removed, but as the condition be- 
comes more advanced the pain not only 
becomes more severe, but continues 
after the use of the feet is stopped, 
and in the severer cases persists during 
part of the night. The severity of the 
pain may be greater than is to be ex- 
pected from the amount of distortion. 
The pain is most frequent in the neigh- 
borhood of the scaphoid ; it occurs also 
in the front of the foot, in the centre of the heel, behind the inner 
malleolus, and on the outer border of the foot. Pain is also complained 
of in connection with flat-foot in certain cases in the leg, knee, back, 
or hip. 

Tenderness. — Tenderness is seen over points of ligamentous 




FIG. 526.— Outline Drawing (from Pho- 
tograph) in Normal and Pronated 
Position. Showing Forward Excur- 
sion of Mark over External Malleo- 
lus in the Pronated Position. 



FLAT-FOOT AND OTHER DEFORMITIES. 575 

strain ; it occurs under the scaphoid, under the centre of the heel, be- 
hind the internal malleolus, at the outer border of the foot, and in the 
great toe-joint. It is rarely absent and may be found in one or more of 
these situations, according" to the type of the distortion. 

Muscular Spasm. — In very acute cases there may be irritability 




FIG. 527.— Displacement of Little Toe. (H. L. Burrell.) 

and contraction of the peroneal muscles holding the foot in the position 
of abduction ; in this case there is apt to be tenderness over the origin 
of the peroneal muscles. Irritability of the gastrocnemius frequently 




a b 

Fig. 528.— a, Flat-foot ; b\ Flat-foot with Eversion. (Children's Hospital Report.) 

exists, and tenosynovitis of the tibial and peroneal muscles is occasion- 
ally seen. 

Stiffness. — Congestion of the foot and swelling of the foot and 
leg are frequent symptoms. Stiffness or loss of flexibility is a symptom 
which is gradually developed, and it involves at first and most promi- 



576 



ORTHOPEDIC SURGERY 



nently the mediotarsal joint. The stiffness is such that the front of the 
foot cannot be adducted actively or passively as much as it normally 
should be. This is an important matter to recognize, as it prevents an 
assumption of a correct position by voluntary muscular effort until the 
proper flexibility is restored. There is also, especially in the later his- 
tory of the case, some limitation in the plantar and dorsal flexion of the 
foot at the ankle-joint. 

In severe flat-foot, owing to the change in the form of the bones, 
there is a limitation in the amount of motion at the ankle-joint. The 
normal amount of motion, which should be 8o°, in flat-foot may be re- 
stricted to 30 or 40 . 

Gait.— The gait becomes modified as the affection progresses and 
becomes in a measure characteristic. The feet are generally more 

everted than normal, and in painful cases it 
will be noted that in standing the patient 
deliberately throws the foot over, so that 
the weight is borne more upon the inner 
border than is normal. There is a lack of 
elasticity to the gait, and this is a symptom 
often complained of by the more intelligent 
patients, who find their feet stiff and 
clumsy. After .the patient has been sit- 
ting for some time and on rising in the 
morning the feet are likely to be stiff and 
clumsy. 

Contracted Foot. — Mention should 
be made of a type of painful affection of the 
foot often seen in practice, in which the 
symptoms of muscular irritability and con- 
traction predominate. It may be an accom- 
paniment of mild flat-foot or it may exist 
in connection with a highly arched foot. 
Such feet cannot be dorsally flexed beyond a 
right angle, and perhaps motion may be restricted in other directions. 
Pain and irritability in walking may be noticed in the calves of the legs as 
well as in the arches of the feet, and even backache may be present. 
This variety of irritable and strained foot is probably one of the affec- 
tions described as " contracted foot " 1 or " non-deforming club-foot." 2 
It is apparently due to the strain and bad balance induced by wearing 
improper and ill-fitting shoes. It is most commonly seen in women of 
the upper classes. 

'Lovett: Art. "Orthopedic Surgery." Park's "System." 2d ed.— Whitman : 
" Orth. Surgery," 2d ed.. p. 699. 

'Shaffer: N. Y. Med. Rec.,May23d, 1885; N. Y. Med. Journ., March 5th, 1887. 




Fig. 529.— Boot for Left Foot 
Worn by Patient with Severe 
Flat-foot, Showing Character- 
istic "Treading- Over " of Shoe. 



FLAT-FOOT AND OTHER DEFORMITIES. 



S77 



Symptoms in Children. — In young children the symptoms are 
somewhat modified. Pain is not a common symptom, and rigidity in 
the deformed position is rare. The amount of flattening is on the aver- 
age greater than in adult cases when the child is in the standing posi- 



.*££, 




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1 


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Fig. 530. — Radiograph Showing Compression of Left Foot by Boot. 



tion. The child tires easily, is not steady in walking or light on the 
feet in movements requiring balance, and falls frequently. Associated 
with the flattened foot there is often to be found in young children an 
abnormal lateral mobility of the knee-joints. 1 

^ourn. Am. Med. Assn., April 18th, 1903. 
37 



573 ORTHOPEDIC SURGERY. 

Diagnosis. — The recognition of a static disturbance in the foot suffi- 
cient to give rise to pain is to be made partly from the history of the 
case, and partly from the examination of the foot. The characteristic 
symptoms have been already indicated. 

For examination of the feet, the shoes and stockings should be re- 



FlG. 531.— Radiograph Showing Right Foot Uncompressed by Boot. 

moved and the patient should stand facing the surgeon upon the floor 
or upon a plate of glass with a mirror underneath. 

The relation of the foot to the leg should be noted, whether the in- 
ternal malleolus is unduly prominent and the foot rolled over on to its 
inner border. The height of the arch of the foot is of importance, and 



FLAT-FOOT AND OTHER DEFORMITIES. S79 

any lowering of the inner border is significant. The rolling of the 
foot further on to its inner side or the lowering of the arch after the 
patient has stood for a minute indicates muscular insufficiency under 
weight-bearing. 

If, in addition to its outline, the sole of the foot is inspected by 
means of the mirror, the normal foot will show an evenly distributed 
anaemic area, the weakened foot will bear more weight at its inner sur- 
faces at the front and back of the foot, and will roll over further under 
the influence of muscular fatigue. 

The impression of the weight-bearing foot is of interest, but not of 
great diagnostic value. In the tracing as ordinarily taken the non- 
weight-bearing position of the foot is recorded first and then the weight- 
bearing position, the two being superimposed. The abnormal and the 




Fig. 532.— Normal Motion of the Front of the Foot. 

normal imprints are shown in the accompanying illustrations. The 
impression of the foot is taken by having the patient step on a piece of 
cardboard blackened with camphor smoke. 

The degree of flexibility should be examined by attempting to ad- 
duct the forefoot gently with the hands and to flex the foot dorsally 
with the patient's knee extended. Loss of the first of these move- 
ments is of diagnostic importance. 

The presence of tender points in the sole of the foot, either under 
the heel or under the scaphoid, generally indicates static disturbance 
of the foot. 

The range of variation in the contour of the foot and in the height 
of the arch in individual feet is so marked that from inspection it is not 
possible to say that a foot may or may not be the seat of symptoms. 
A foot apparently anatomically sound may give rise to symptoms, 
while, on the other hand, one excessively rolled in may be perfectly 
useful. 1 

Differential Diagnosis. — Rheumatism and Arthritis Deformans. — 
The diagnosis of " rheumatism " in the feet should be made with very 
great care and only in connection with distinctly rheumatic manifesta- 

1 Lovett : " The Occurrence of Fiat-Foot among Trained Nurses." Am. Journ 
Orth. Surgery, vol. i.,.i. 



580 ORTHOPEDIC SURGERY. 

tions in the upper extremities. Pain in the knees, hips, and back may 
be purely secondary to a static disturbance in the foot. The frequency 
with which this diagnosis is made by practitioners unfamiliar with flat- 
foot makes it important to lay much stress on this point. The fact 
that no dropping of the arch of the foot can be detected by the eye by 
no means establishes the diagnosis of rheumatism. 

An „r-ray examination is of assistance in determining any displace- 
ment in the relation of the bones to each other occurring in the severer 
grades of the affection and not present in the lighter grades. It is 
also of value in giving information as to the presence of arthritis defor- 
mans and the existence of spurs of bones. 

Prognosis. — After a time the foot may become accustomed to its 
altered position and painful symptoms cease. In other cases, however, 
the painful symptoms continue and become worse rather than better. 

The condition may persist almost indefinitely, a constant source of 
pain and disability. 

The results of treatment are as a rule satisfactory. In cases with 
little permanent distortion but great muscular weakness, benefit and 
cure can be expected from careful treatment. In cases of average 
severity, relief can almost always be given by very simple measures. 
A spontaneous cure is not to be expected. 

Even after deformity of the bone takes place and the distortion is 
confirmed, a useful foot may be obtained if the muscular development 
of the leg is good. Severe deformity can be corrected by operative 
measures, with the restoration of normal function by after-treatment. 

Treatment. — The treatment of the conditions described will depend 
upon the nature of the deformity, its severity, and its duration. 

The principles of treatment are simple. They consist of the sup- 
port of the foot in a proper position (if support is needed) and the de- 
velopment of the strength of the muscles and tissues until they are 
sufficiently strong to maintain the normal attitude. Where fixed dis- 
tortion of the foot is present, it is to be corrected by mechanical or 
operative measures. 

Supporting Treatment. — Plates. Indication for Support. — When 
the strength of the foot is inadequate to sustain the weight of the body 
without discomfort, mechanical support is needed. Flat-foot plates 
(Chapter XXL, 32) are indicated in such cases even when the lower- 
ing of the arch is not marked to the eye, but when the symptoms of 
strain are sufficiently characteristic, as described above. Plates are not 
likely to be of use in rigid and deformed flat-foot where it is not possi- 
ble to obtain an improvement in position by gentle manipulation. In 
such cases the restoration of a more correct position should precede the 
use of plates. 

Casts for Plates. — For the construction of a properly fitting plate a 



FLAT-FOOT AND OTHER DEFORMITIES. 581 

cast of the foot is necessary. This is made from a plaster mould of the 
foot placed in as near a correct position as is possible. The patient is 
seated and the foot is placed in a pan of plaster of Paris and water of 
about the consistence of melted ice cream. No weight is put upon the 
leg during this proceeding, and the plaster is heaped up around the 
inner side of the ankle and is allowed to harden. The foot is then re- 
moved from the mould, which is greased with vaseline and filled with 
plaster-of -Paris cream. When the latter hardens it is removed from the 
mould and gives a representation of the patient's foot in a somewhat 
corrected position. As this cast furnishes a somewhat sharp contour 
of the sole of the foot, a plate shaped exactly to it would be likely to 
present rather sharp contours and not be so comfortable as a somewhat 
modified shape. It is therefore necessary for the surgeon with a 
sharp knife to cut away something of the lower surface of the cast in 
order to insure in the plate an even, well-distributed bearing surface, 
pressing most on the points where pressure is desired. It must be 
remembered that the plate should furnish support to the hard tissues 
of the foot and not to the soft, and in fat feet more modification will be 
necessary than in thin ones. It is also necessary, if the plate is to be 
properly balanced and set evenly, that the surgeon should cut the cast 
where the front and back edges of the plate come, in such a way that 
they should be flat and approximately in the same plane ; otherwise a 
rocking plate or one with uneven edges will result. 

Another method of preparing casts for plates is to model them 
from moulds of the foot made in dental wax. If a sheet of quickly 
hardening dental wax is softened in hot water and placed upon the bot- 
tom of the foot, a mould can be taken. When it is hardened it can be 
removed from the foot, and can be cut and moulded to any desired 
shape by immersion again in hot water. In this way a wax flat-foot 
plate is made fitted to the boot. A plaster-of-Paris cast can be taken 
of this, and reproduces exactly the shape and size of the plate desired. 

Manufacture and Material. — The best all-round material for the 
manufacture of plates is a spring tempered steel of a gauge varying 
from eighteen to twenty, according to the weight of the patient. For 
the manufacture of plates from this material, the services of an instru- 
ment-maker or of a skilful blacksmith are necessary. The cast should 
be furnished to him and the plate forged to fit the cast exactly. It 
should then be tried on the patient, before or after which it should be 
tempered. For final use the plate should be copper-plated and nickel- 
plated. In other cases it is more convenient to cover it with leather, 
but the moisture of the foot is more likely to rust it under these con- 
ditions than when it is nickel-plated. Galvanizing furnishes a perma- 
nent protection against rust, but the process destroys or impairs the 
temper of the plate. A galvanized plate should therefore be made 



582 ORTHOPEDIC SURGERY. 

heavier than others. Of other material used for the manufacture of 
plates should be mentioned phosphor bronze, which is malleable and 
more easily fitted, but plates made from it are much heavier than of 
tempered steel. Sheet celluloid may be used for the manufacture of 
plates, but in order to support weight it has to be very thick, and even 
then is inclined to bend or break. It has the advantage that the sur- 
geon can make and shape his own plates. The celluloid is cut of the 
desired shape and is bound on to the bottom of the cast by rubber tub- 
ing, which is wound round both cast and plate on the stretch ; it is then 
immersed in boiling water, which softens it until it takes the shape of 
the bottom of the cast. The edges should be smoothed with a file. 

Another efficient but somewhat clumsy use of celluloid may be made 
by the surgeon. A celluloid paste is made by dissolving celluloid chips 
in acetone ; this is then painted on to several layers of gauze laid on the 
cast, between which strips pieces of steel wire are incorporated. The 
wires are laid on in different directions, giving strength as desired. 
When the celluloid has hardened, the edges of the plate should be 
trimmed. 

Shape of Plates. — -Judgment is necessary in determining the proper 
shape of the plate in each case, as the deformity varies both in degree 
and in kind. The shape should be determined by the part of the foot 
which needs corrective support. In the milder cases all that is needed 
is to furnish support to the sustentaculum tali. In other cases the 
scaphoid, cuneiform, and proximal end of the first metatarsal need to 
be raised. In some cases the tendency of the os calcis to rotate to the 
inner side of the foot is to be checked, and in other cases side pressure 
is needed on the head of the astragalus, scaphoid, and cuneiform, with 
counter-pressure on the outer side of the foot. The most practical 
way of determining what shape of plate is desirable is to have the 
patient stand, and by pressure with the hand to see in what place the 
force accomplishes the best result. In general, a plate should be higher 
along the inner part of its surface than on the outer, but it should not 
be made so sloping that the foot continually slides off. If this is the 
case a counter-point of pressure may be furnished by turning up the 
outer flange at the outer edge of the plate. Ordinarily it is advisable 
to have the plate support nearly the whole width of the sole, ending in 
front behind the sesamoid bones of the great toe and at the back end 
just anterior to the weight-bearing surface of the heel, or, if desired, 
running to the back of the weight-bearing surface of the heel. 

If the anterior part of the foot is broken down, support to it should 
be furnished by raising the front of the plate in a dome-shaped rise, sup- 
porting the part of the foot behind the heads of the metatarsals. In 
flexible feet a shorter plate can be used than in rigid feet. The need 
of an inner flange and its height will be determined by the require- 



FLAT-FOOT AND OTHER DEFORMITIES. 5 8 3 

ments of the case ; the same is tme f the outer flange. The plate at 
its outer border should not project beyond the outer edge of the shank 
of the boot, or it will push out the leather and destroy the shape of the 
boot. 

Fitting and Use. — The plate should be shaped in such a way as to 
act as a prop to the portions of the feet which drop to an abnormal po- 
sition when weight is thrown upon them. In the practical fitting of 
the plate, if the plate is rightly shaped, the foot when not bearing weight 
should lie smoothly against the bottom of the plate, not springing off 
at the front or back. If it springs off, it will exert more pressure than 
is generally comfortable. When the plate is placed in the boot and the 
patient stands upon it, there should be a sense of even, well-distributed 
pressure, and not a feeling as if the patient were standing on a ridge 
or lump, which will be the case if the plate is too high. If an inner 
flange is used it should not press too much upon the foot when weight 
is borne upon it. If sensitive points in the foot are present and cause 
pain when weight is borne upon the plate, it will be necessary to lower 
the plate opposite these points. When the plate is first applied it 
should be worn only for so long a period as is consistent with the com- 
fort of the patient, and should then be taken out to rest the foot if nec- 
essary. If the plate is persistently a source of pain it will not give the 
desired relief, but will cause irritation and must be lowered until it is 
comfortable. No point is more commonly neglected than this, and the 
very common use by patients of ill-fitting supports bought at shoe-stores 
brings much discredit upon the use of plates. The plate should set 
firmly in the shoe and should not rock, and the front and back ends 
should be in contact with the sole of the boot. 

Misuse of Plates. — The danger of injury to the feet by the too con- 
stant use of plates is to be borne in mind. The plate is to be regarded 
in the same light as is a crutch or cane in the case of any joint unable 
to bear the strain of use, and is to be discarded when the normal 
strength has returned and the irritability has disappeared. To continue 
the plate after the indications for its use have disappeared is to hamper 
the muscles of the feet and to prolong the unnatural condition. 

Discontinuance of Plates. — When the symptoms of irritation have 
disappeared, a trial of the strength of the foot is to be made by discon- 
tinuing the plate for a short period and by teaching the patient to hold 
the foot by muscular effort in the corrected position. When the plate 
is first left off, prolonged standing and walking are to be avoided, and 
if symptoms of irritation follow its discontinuance it should be reap- 
plied. It is a mistake to discontinue the plate suddenly or for the pa- 
tient to continue to go without it if symptoms of strain are present. 

Pads. — The use of felt or leather pads supporting the arch of the 
foot is sometimes of use temporarily or under exceptional conditions. 



584 ORTHOPEDIC SURGERY. 

Such pads may be cut of the desired shape and worn outside the stock- 
ing by being fastened on temporarily by a tape passing round the foot 
or by being incorporated in an inner sole of leather. If they are worn 
for any length of time the weight of the foot stretches the leather of 
the boot and breaks down the shank and they cease to be of value. 
Felt or leather pads are frequently of use in persons with mild flat-foot 
who have to exercise or stand in gymnasium shoes. 

TJie Oblique Sole. — Palliative treatment is often attempted in cases 
of flat-foot by making the inner side of the sole and heel of the boot 
one-eighth or one-fourth of an inch thicker than the outside. The 
weight is in this way thrown more to the outer side of the foot and the 
strain on the inner side is somewhat relieved. The thickness of the 
wedge which is necessary may be determined experimentally by build- 
ing up the inner side of the boot till the desired position is obtained, as 
determined by the diminution in the projection of the internal malle- 
olus. The objection to the method is that the foot slides on the incline 
of the sole if an effective elevation in the sole of the boot has been 
made and the boot is distorted by the stretching of the leather over the 
outer side ; in addition to which, the pressure of the outer side of the 
foot against the boot is uncomfortable. 

It is to be remembered that in the correction of flat-foot not only 
should the body weight fall well on the outer edge of the foot, but the 
great toe and head of the first metatarsal should perform their normal 
functions in locomotion. The method is sometimes useful in the flat- 
foot of children and in connection with the use of plates ; in the latter 
case a slight elevation will sometimes diminish the strain on the inner 
side of the foot. Of itself, however, it must be regarded as a very im- 
perfect method. The raising of the inner edge of the heel of the boot 
without changing the sole has the advantage of checking somewhat the 
inclination of the os calcis to roll to the inside. 

Massage, Gymnastics, etc.— The supportive treatment of flat-foot 
should be reinforced by measures to stimulate the local circulation and 
to strengthen the muscles of the foot. Massage is of the first impor- 
tance, but should not be pushed to the point of irritation. The use of 
alternating hot and cold douches or of a local hot bath followed by a 
cold douche is of much value. Vibratory massage, electricity, and the 
use of hot air may be of use in especial cases. ' Exercises to increase 
the power of the deficient muscles are sufficient, in connection with the 
measures already mentioned, to correct many of the milder cases. They 
form an important part of the treatment of all cases, mild or severe, 
whether or not used in connection with support to the arch, and are to 
be regarded as essential to treatment of any form. The toeing-out 
habit in standing and walking should be corrected. Individuals with 
strong and untrammelled feet stand and walk with but little divergence 



FLAT-FOOT AND OTHER DEFORMITIES. 585 

of the angle of the feet. The greater the angle of divergence in walk- 
ing and standing, the greater the tendency to strain of the tissues and 
to falling of the foot to the inner side. 

Shoes. — Typical flat-foot, being a static deformity, is in general to 
be prevented if proper precautions are taken. Of these the most im- 




F Ir '- 533- — Showing' Shoe Constriction of Front of Foot, with Normal Foot in Shoe Before 
and After Removal of Upper. 

portant is footwear which does not distort or interfere with the free 
movements of the foot. In infants beginning to walk, in whom the 
body weight may be too great for the muscular strength, trouble may 
be averted by massage and manipulative treatment, the avoidance of 
great fatigue, and the use of proper footwear. In older children with 
the same defect, gymnastic development of the muscles of the feet 
should be followed out and faulty shoes avoided. 

The adoption of proper footwear is essential not only to protect a 
foot under treatment for flat-foot from relapsing to its deformity, but 



586 



ORTHOPEDIC SURGERY 



also as a preventive measure in young children. The object of a boot 
should be to hold the foot in an approximately correct position and not 




Fig. 534. — «, Drawing of Normal Position of Bones of Foot, b, Fashionable Shoe, c, Tracing 
of Skiagram of Foot in Shoe, Indicating Cramping and Downward Pressure on the First 
Metatarsal. 

to interfere with the normal function of the foot in walking. It is ob- 
vious that the great toe should have room to help support the inner 




Fl G. 535.— a, Photograph of Humped Foot. £, Tracing of Skiagram of Humped Foot with 
Irritation Exostosis of the Metatarso-cuneiform Articulation. 

border of the foot ; that the forefoot should not be cramped, but should 
have room to be placed properly on the ground, in order to perform its 



FLAT-FOOT AND OTHER DEFORMITIES. 



587 



weight-bearing function ; and that the toes should be given room and 
opportunity to touch the ground in their proper relation and thus be of 
use in walking, and that the outer edge of the foot should have an op- 
portunity to exert its normal function in supporting the body weight. 
These requirements necessitate that the boot or shoe should have a 
straight inner line, that the shank should be as high as the shank of 
the individual foot when bearing slight weight. This should not be too 
stiff, permitting the normal play of the first metatarsal inward and 





FIG. 536.— Tracing of Skiagram of Foot in Shoe Before and After Removal of Upper. 

•downward, and should be slightly higher at its inner than its outer bor- 
der. The forward part of the boot should be as wide as the weight- 
bearing foot at that point, and the toes should have room to be placed 
individually on the ground. The forward part of the sole should not be 
rolled up, but should be flat, to enable the toes to finish the step in 
walking ; neither should the lower surface of the sole be convex from 
side to side, but should set squarely on the ground. The heel should 
not be high. The forward part of the boot should be at somewhat of 
.an angle to the line of the long axis of the heel, that is, the forefoot 
should be slightly adducted on the posterior part of the tarsus. Since 
the position of the weakened foot is one of abduction of the forefoot, 
and the position of the foot under muscular support is one of adduction 
of the forefoot, it is obvious that the support of the foot in the former 



588 



ORTHOPEDIC SURGERY. 



condition is corrective in character. The upper should not be shaped 
too snugly upon the dorsum of the foot or be so inelastic as to prevent 
the flexible action of the toes. 

The shape of the shoe has become conventionalized to such an ex- 
tent that the general use, among the leisure class, of shoes of the shape 
of the normal foot is not practicable. The people of the city streets 
will not be shod as hunters. . It is, however, practicable to limit the use 
of fashionable shoes for leisure hours and working boots for working 
hours. The boots should be adapted to the gait and use. People who 
use the front of the feet in locomotion, "front-foot " walkers, and those 
walking on uneven ground need more room in the front of their boots 
than heel walkers or those who walk on an even surface. Individuals 




Fig. 537.— A Shoe Arranged so as not to Cause as much Pressure on the Dorsum and Pre- 
venting the Distortion. 

with any tendency to flat-foot should have walking boots as well as 
dress boots, and the feet should be rested as much as possible in san- 
dals and moccasins. 

The Treatment of Painful Cases.— In certain cases the symp- 
toms of local irritability reach so high a grade that especial treatment 
is needed. Spasm of the peroneal muscles may be present, holding 
the foot in an abducted position and resisting movements of rectifica- 
tion. In this case temporary fixation of the foot in a plaster bandage 
is the most efficient measure. In other cases great irritability is'caused 
by a tenosynovitis from joint inflammation incident to strain, and in 
these cases the treatment described for sprain of the ankle is necessary. 
Irritated flat-foot, however, is not so favorably affected by massage as 
the ordinary sprain of the ankle. 

Support to the Leg and Foot.— In the severe forms, when there 



FLAT-FOOT AND OTHER DEFORMITIES. 5^9 

is decided eversion of the foot, a support holding the leg is needed. 
Such may be afforded by means of a steel sole plate, with an upright 
passing up on the outside of the leg, with a supporting strap around the 
inner malleolus described in speaking of infantile paralysis, or as a sim- 
ple upright attached to the outer side of the sole of the boot, with a 
leather support over the inner malleolus secured to the upright (Chap- 
ter XXL, 31). 

Forcible Correction. — In cases in which it is not possible to place 
the foot in an approximately correct position on account of stiffness 
and muscular contraction, it is generally unsatisfactory to attempt 




FlG. 538. — Deformity Caused by the Constriction and Confinement of the Foot. 

the use of a support until the position of the foot has been corrected. 
Such patients should be anaesthetized and the foot forcibly twisted into 
shape. It must be remembered that there are two elements of deform- 
ity to be corrected : first, eversion of the foot ; and, second, abduction 
of the forefoot. This can be done manually in many cases, but in severe 
cases such an appliance as the Thomas club-foot wrench will be of use 
in giving better leverage, or the foot can be manipulated over a padded 
wooden wedge. 

The foot should be overcorrected if possible, or in any event placed 
in the best obtainable position and held by a plaster bandage. It then 
follows the course of an ordinary sprained ankle, generally of slight de- 
gree. As soon as the patient can walk without pain, supports should 
be applied. 



590 ORTHOPEDIC SURGERY. 

In less severe cases correction can be gradually accomplished by 
the repeated application of plaster-of -Paris bandages. 

In extreme cases osteotomy of the neck of the os calcis and astrag- 
alus may be needed. 

The removal of a wedge-shaped piece of bone from the inner side of 
the midtarsus has been recommended, but should not be undertaken 
unless it is certain that the chief obstacle to correction lies in the dis- 
torted shape of the astragalus, scaphoid, and os calcis. In a majority 
of cases, even the severe ones, forcible correction will be found more 
efficient than wedge-shaped exsection, as the distortion will be found to 
be distributed in various parts of the foot, and extensive removal of 
bone will be followed by weakening of the foot. The operative details 




Fig. 539. 



-Forcible Correction of Valgus on Wooden Block. (Berger and Banzet.) 



for osteotomy and wedge exsection are similar to those to be regarded 
in operating on club-foot, it being remembered that the deformity is 
the reverse of club-foot. 

The most notably deficient muscles are the tibialis posticus, the 
tibialis anticus, the flexor longus hallucis, and the short muscles of the 
sole of the foot. The following simple exercises will be found useful: 

The patient walks on the outer edge of the foot with the inner edge 
raised. 

The patient attempts to separate the great toe from the second 
toe laterally and to hold it in that position while walking. 

The patient flexes the toes while the foot is free and grasps objects 
in them by their plantar surface. 

The patient walks with the front of the foot directed inward. 

The patient sits with the leg extended and resting upon the assist- 
ant's knee. Forcible adduction of the forefoot is then made while the 
assistant resists lightly with one hand steadying the tibia and the other 
pressing against the ball of the great toe. 

The patient should be taught to rise on the toes at the end of each 
step, finishing the step with the toes. 



FLAT-FOOT AND OTHER DEFORMITIES. 591 

The patient should place the feet together in a parallel position, rise 
upon the toes as far as possible, and turn the heels, and, with the feet 
in this position, lower the body by bending the knees. 

Such exercises as the surgeon directs should be performed an in- 
creasing number of times each day. 

Certain other painful affections and acquired deformities of the feet, 
are sufficiently allied to flat-foot to be considered in this connection. 

METATARSALGIA. 
(Anterior metatarsalgia, Morton's disease.) 

This name is used to describe a cramping pain more or less spas- 
modic, situated between the distal end of either of the outer three 
metatarsal bones. It was first described by T. G. Morton, 1 of Phila- 
delphia, in 1876. 

Causation.— The pain is due to a disturbance in the normal relation 
of the anterior ends of the metatarsal bones, causing a pinching of the 
external plantar nerve^between the ends of the bones, or to pressure of 
the metatarsals on other digital nerves, or to abnormal strain upon the 
ligaments connecting the metatarsal heads. 2 

The affection is thus due to the disturbed relation in the position of 
the metatarsals caused by faulty footwear. Normally the head of the 
first metatarsal bears a large part of the weight which comes upon the. 
front of the foot. If footwear is worn which gives insufficient room 
for the toes and at the same time exerts a crowding pressure upon the 
metatarsals, the heads of the first and fifth metatarsals are unable to 
drop to the normal plane below the level of the other metatarsals, owing 
to the narrowness of the shoe. The weight therefore falls unduly on 
the heads of the other metatarsals, which are crowded downward as the 
foot slips forward in the boot. 

Symptoms. — The condition is characterized by a more or less severe 
pain, which radiates down into the toes and often up into the leg. The 
pain usually appears when the patient is walking. It occurs generally 
between the third and fourth or fourth and fifth toes. It may be pre- 
ceded by a sensation of slipping between the ends of the metatarsals, 
or the slipping may occur without the pain. It ordinarily comes on 
when the boots are on, but may sometimes be occasioned by rising on 
the toes in the stocking feet. The patient seeks relief instinctively by 
removing the boot and manipulating the foot, which relieves the acute 
pain. Some soreness may remain afterward and a tender spot is often 
found at the seat of the pain. 

The attacks of pain may become gradually more frequent and more 

1 Amer. Journ. Med. Sciences, 1876. 

-Jones: Liverpool Med. -Chir. Journ., January, 1897. 



59 2 ORTHOPEDIC SURGERY, 

severe until a condition of disability is established, the patient dreading 
walking. Spontaneous recovery may occur, but is uncommon. 

The foot may be normal, so far as can be ascertained on inspection. 
Oftener, however, one or. more of the following variations from the 
normal may be detected. 

i . The foot may be weakened and the standing position show slight 
dropping of the arch. 

2. The anterior arch of the foot, or the arch normally formed by 
the heads of the metatarsal bones, if looked at in a cross section of the 
foot, is relaxed and flattened. The heads of the second, third, and 
fourth metatarsals are on a lower level than normal. 

3. Dorsal flexion of the foot may be limited on manipulation. 
Callosities may be found under the heads of the metatarsals, and 

one or more of the metatarsal heads may be felt unduly prominent in 
the sole of the foot. 

Motion of the toes, especially in severe cases, is apt to be limited in 
the direction of plantar flexion. 

Diagnosis. — This affection is frequently diagnosticated as neuralgia, 
for which only general treatment is prescribed, yet the diagnostic 
symptoms are perfectly well marked and definite and not like those of 
any other affection. 

The prognosis without treatment is not good ; the attacks as a rule 
become more frequent and painful, though spontaneous recovery does 
rarely occur. With proper mechanical treatment most patients recover, 
but occasionally very obstinate cases are seen which resist all the ordi- 
nary methods of treatment. 

Treatment. — It is obvious that if any static deformity of the foot 
exists it should be corrected. If the weakened foot is present a proper 
plate should be applied, brought well forward with an elevation behind 
the distal ends of the metatarsals. If the anterior arch is relaxed and 
flattened, a felt or metal pad should be placed under it behind the heads 
of the metatarsals. In short, measures should be adopted to relieve 
the front ends of the metatarsals from pressing down on to the sole of 
the foot in finishing the step in walking. 

Proper boots with a broad sole should be worn, and compression of 
the front of the foot by boots should be avoided. The normal flexibility 
of the toes should be cultivated by proper exercises. In some cases, 
however, compression of the shafts of the metatarsals for a time affords 
relief. In these cases it can be afforded by adhesive plaster, by band- 
aging, or by a boot made tight over the shafts of the metatarsals. Re- 
moval of the distal end of the fourth metatarsal has been advo- 
cated as a measure of treatment, but it is not often necessary to resort 
to this. 



FLAT-FOOT AND OTHFR DEFORMITIES. 



593 



HALLUX VALGUS. 

This name is applied to the outward displacement of the great toe. 
In the normal foot, as seen in children and people who do not wear 
boots, the long axis of the great toe when prolonged backward passes 
through the centre of the heel (Meyer's line). 

Causation. — This deformity of the great toe, however, is not neces- 
sarily the result of tight shoes, for the deformity may come in people 
who have worn only comparatively loose ones. The upper leather of 

shoes, being more yielding than the 
sole, stretches under the pressure 
of use, or is stretched to avoid 
pressure upon the metatarso-pha- 
langeal articulation. The boot is 
not stretched at its extreme end 





Fig. 540.— Hallux Valgus. Great toe under. FIG. 541.— Hallux Valgus. Great toe over. 

and it inevitably becomes, in a degree, conical in shape on this account, 
being broader across the ball of the foot than at the tip end. In the act 
of walking the foot necessarily slips inside of the boot to a certain extent, 
and if the shoe slips backward and the foot forward, a certain amount of 
pressure will come upon the inner side of the end of the great toe, 
tending to displace it outward. 

This deformity may also be occasioned by short boots, and the ordi- 
nary pointed-toe boots, or any boot which does not give more room for 
lateral spreading at the toes than at the metatarso-phalangeal articula- 
tion, would necessarily give rise to the trouble. Stockings are also a 
factor in its production. 

38 



594 



ORTHOPEDIC SURGERY. 



Symptoms. — When the deformity continues for any length of time, 
alteration in the relation of the bones of the metatarso-phalangeal joint 
takes place. The head of the metatarsal is partly uncovered as the 
phalanx is pushed to the outer side, and the head of the metatarsal may 
become enlarged from growth of the bone due to periosteal irritation. 
The skin over this prominent joint may grow thick and a bursa form 
over it. This may become inflamed, giving rise to an extensive cellulitis, 




FIG. 542. — Shoes Causing Hallux Valgus, Crowded Little Toes, and Weakened Toes. 



which may include the whole dorsum of the foot, which may suppurate 
and cause necrosis of the bone. This latter termination is, however, rare 
and occurs only in neglected cases. The inflammation of this bursa is 
known as a bunion. 

The symptoms due to hallux valgus in the non-inflammatory stages 
are chiefly those resulting from the alteration of the shape of the foot. 
In aggravated cases a peculiar gait is noticeable, the foot is thrown 
out, and there is loss of elasticity in the gait. There may be pain and 
irritability in the great toe-joint, and in severe cases extreme pain and 
difficulty in walking, which is usually attributed by the patient to gout. 



FLAT-FOOT AND OTHER DEFORMITIES. 



595 



On examination, sensitiveness of the metatarsophalangeal joint is de- 
tected on pressure. In its more marked degree it is almost exclusively 
an affection of adult life, but is occasionally seen in adolescence. In a 
slight degree it is almost universally present after middle childhood. 




FlG. 543. — J^T-ray of Hallux Valgus, Showing how the Shoe Causes a Deformity. 

Treatment. — The treatment of hallux valgus in early cases may be 
carried out by wearing a splint of steel or hard rubber along the inner 
border of the foot fastened behind to the metatarsus. To the front end 
of this splint the toe is bandaged or strapped and thus pulled outward. 

The use of a toe post is sometimes beneficial. That is, a metal 

partition is attached to or passed up through the sole of the boot, which 

shall come between the first and second toes and hold the great toe in 

an improved position. 1 For the use of this toe post a stocking is re- 

1 Sampson : Johns Hopkins Bulletin, January, 1902. 



5 9 6 



ORTHOPEDIC SURGERY. 



quired which shall have a division between the great toe and the other 
toes (Chapter XXI., 33). The use of a foot-plate curved to support 
the arch of the foot will be of use when the foot is weakened or flat. 

Shoes should be so constructed that no pressure is possible which 
will force the great. toe to the outer side. The sole of the shoe should 
be not only as broad as the sole of the foot, but in cases in which there 
is a tendency to this deformity, room should be made in the front of 
the shoe for the first metatarso-phalangeal joint. 

Operation. — In old cases attempts to correct the deformity by such 
means as those mentioned are generally unsuccessful and operative 




Fig. 544.- -Hallux Valgus or Out-toe. 



measures may be adopted. The joint may be resected through an in- 
cision along the inner and upper surface of the joint. 

The ends of the bones composing the joint are then exposed and 
dissected freely enough to be pushed out of the wound one at a time. 
The articular surfaces are sawed through or cut off with heavy bone 
forceps in such planes that when the cut ends are in apposition the toe 
will lie in the desired straight line. The wound is then closed and a 
plaster-of-Paris bandage applied over the antiseptic dressing, which 
must be applied with much care of the position of the toe. Wiring of 
the bones is not necessary. 

The use of properly made shoes is essential for after-treatment, and 
also for the prevention of the increase or recurrence of the deformity. 



FLAT-FOOT AND OTHER DEFORMITIES. S97 

HALLUX VARUS. 

This deformity is not a common one, and is known also as in-toe or 
pigeon-toe. It is rarely of any importance, and although often con- 
genital in origin, it may occasionally be seen in young children with 
flat-foot, and the writers have observed it in a few cases of overcor- 
rected club-foot in which a valgus has resulted. It is also seen in con- 
nection with severe knock-knee at times. 

This distortion does not generally require treatment, and the use of 
ordinary shoes is sufficient to correct the deformity. 

HALLUX RIGIDUS. 

This deformity is sometimes seen in adolescents, and is a stiffness 
of the metatarso-phalangeal joint of the great toe. The deformity may 
may be a flexion of the proximal phalanx of the great toe through 30 
to 6o c , with extension of the second phalanx, or the joint may be rigid 
in the straight position. 

The symptoms vary with the stage of the disease. Early there may 
be slight pain over the joint and painful motion, but the cases rarely 
come to the surgeon's notice at this time. Later there is swelling over 
the joint, with tenderness, and perhaps an enlargement of the bone 
itself. The usual atrophy after ankylosis often occurs here. 

The condition is often associated with flat-foot. Ill-fitting shoes also 
have an influence in causing the distortion. At times it arises from an 
injury. 

The treatment in the early stages will consist in removing the excit- 
ing cause and properly supporting the foot. If there is pain, with signs 
of inflammation, rest with local applications is indicated, and later pro- 
tection by splints with support of the arch of the foot. In inveterate 
cases excision of the joint may be necessary. 

HAMMER TOE. 

This deformity consists of a claw-like contraction of one of the toes, 
usually the second or third. The condition is one of flexion of the 
second phalanx, with extension of the third, so that the pressure on the 
ground is sustained by the distal phalanx. Over the upward projecting 
joint there is usually a callosity, which may cause considerable annoy- 
ance. 

The origin of the deformity is not well understood, but in some 
cases it is apparently caused by short boots. 

In the slight degrees and early stages of the deformity the patient 
experiences but little discomfort, and such cases are not, therefore, 



59^ ORTHOPEDIC SURGERY. 

commonly seen by the surgeon in this stage. Later, however, locomo- 
tion becomes difficult and painful. 

In children and adolescents the deformity can generally in all but 
the severest cases be corrected by simple mechanical treatment. The 
toe should be bandaged or strapped to a rigid plantar splint, which can 
easily be made of tin. The strapping should be renewed often enough 
to keep the toe extended. In children it can be corrected if necessary 
by subcutaneous section of the contracted fasciae, forcible straightening, 




Pig. 545. — Drawing up of the Toes, Caused by Pressure of the Shoe on the Dorsum of the Foot. 

and fixation in a straight position by means of splints and adhesive 
plaster. 

After correction by mechanical means the toe shows a tendency to 
recontract and must be carefully watched. 

Amputation at the interphalangeal joint is of no use, as the proximal 
phalanx remains still elevated. 

In severe cases it is possible to excise the prominent phalangeal 
joint of the toe which projects upward, and, by taking out sufficient 
bone from the phalanges, to bring two bony surfaces together, which 
will unite and keep the toe straight and flat. 

To amputate the second toe when it is affected will cure the de- 
formity, but is objectionable because it leaves a space between the 
great and third toes, into which the great toe is likely to be crowded 
over, resulting in a severe type of hallux valgus. 

FLEXED OR "CLAWED" TOES. 

A contracted position of several toes is sometimes seen, either as a 
result of improper shoeing or as a sequel to a previous paralysis of 
some of the muscles of the foot. It also occurs at times in connection 



FLAT-FOOT AND OTHER DEFORMITIES. 599 

with what is spoken of as contracted foot. The tendons and fasciae 
will be found shortened. 

This deformity is to be treated in the same way as the contraction 
of one toe. In this, as in all similar affections of the toes, properly 
made shoes are necessary to prevent relapse or to secure permanent 
recovery. 

In obstinate cases, all contracted fasciae or tendons should be freely 
divided and the toes retained in a corrected position. 

PAINFUL HEEL. 

A tender and painful area under the middle of the heel exists at 
times, and is spoken of sometimes as "policeman's heel." It seems to 
be associated with any one of three conditions : 

i. The radiograph may show a bony spur projecting forward from 
the front lower edge of the tuberosity of the os calcis. This may or 
may not be associated with exostoses elsewhere in the tarsal bones. 

2. It may be associated with inflammation of the bursa under the os 
calcis. 

3. It may be the expression of a static disturbance (some degree of 
flat-foot), in which the chief strain falls on the posterior insertion of 
the plantar fascia. 

The treatment consists in the application of a foot-plate depressed 
under the painful area. 

POST-CALCANEAL BURSITIS. 

(Achillodynia, Achillobursitis, Anterior Achillobursitis.) 1 

A tender swelling at the junction of the tendo Achillis and os calcis 
is not infrequently met. Plantar flexion of the foot is painful, and the 
patient walks with the foot everted and avoids rising on the toes. The 
affection may be unilateral or bilateral, and is rather resistant to treat- 
ment 2 and liable to recur when nearly well. 

It generally follows a long walk, prolonged skating, or a sudden 
misstep throwing the weight on the toe. At other times it seems to be 
caused by the pressure of the leather at the back of the boot binding 
the tendo Achillis. 

For the milder cases restricted and everted use of the foot, douches, 
and the use of a cane will be sufficient to effect a cure, but the im- 
provement is slow. It is often necessary to remove pressure over the 
painful area by splitting the heel of the boot in the middle line behind 
and setting in a loose piece of leather between the spread edges. 

1 Albert: Wiener med. Presse. January 8th. 1893. 
: Rossler: Deut. Zeit. f. Chir.. lxii.. 1 and 3. 



600 ORTHOPEDIC SURGERY. 

In resistant and very acute cases the application of a plaster-of- 
Paris bandage to the leg and foot will be necessary. 

An inflammation of a superficial bursa between the tendon and the 
skin occasionally occurs from pressure of the boot heel. Its treatment 
obviously consists in the removal of the pressure. 

SYNOVITIS OF THE TENDO ACHILLIS. 

Symptoms somewhat like those described occur at times in connec- 
tion with a tenosynovitis of the tendo Achillis, which is shown by the 
usual signs of swelling of the sheath of the tendon above the os calcis, 
tenderness along its course, and silky crepitus. The affection is readily 
controlled by the milder class of measures mentioned above. 

EXOSTOSES OF THE TARSAL BONES, 

especially of the os calcis, are found from time to time accompanying 
a painful and even a disabling condition of the foot. Inflammation of 
the post-calcaneal bursa has been described in connection with this 
condition. 1 The exostoses are found by skiagraphs. 

The etiology is obscure. The affection is obstinate and recovery 
slow. It is not, as a rule, much benefited by treatment, and the re- 
moval of the exostoses has not regularly been followed by relief and 
should not be undertaken in the very acute stage. 

Rest, dry heat, fomentations, douching, massage, etc., all have their 
place in improving certain cases. Partial relief is often to be obtained 
by the use of a support to the arch of the foot, relieving the heel from 
some of its pressure. 

1 Painter: Orth. Trans., vol. xi. (with bibliography). 



CHAPTER XXI. 
PRACTICAL DETAILS OF APPARATUS. 

r. Plaster-of-Paris bandages.— 2. Celluloid bandages.— 3. Leather splints and 
jackets.— 4. Antero-posterior support for Pott's disease. — 5. Oval ring head 
support.— 6. Anterior head support.— 7. Thomas collar.— 8. Quadrilateral 
back brace.— 9. The gas-pipe bed frame. — 10. Traction hip splint.— n. Con- 
valescent hip splint. — 12. The double upright hip splint. — 13. Thomas hip 
splint. — 14. Thomas knee splint. — 15. Thomas caliper splint. — 16. Jointed 
knee splint. — 17. Fixation ankle splint. — 18. Knock-knee brace. — 19. Bow-leg 
brace. — 20. Anterior bow-leg brace.— 21. Antero-posterior bow-leg brace. — 
22. Tempered steel uprights. — 23. Brace with movable shoulder-pieces. — 24. 
Torticollis brace. — 25. Caliper apparatus for anterior poliomyelitis. — 26. Sup- 
porting leg brace for anterior poliomyelitis. — 27. Equino-varus splint. — 28. 
Apparatus for talipes equinus.— 29. Apparatus for talipes calcaneus. — 30. 
Apparatus for talipes varus. — 31. Apparatus for talipes valgus. — 32. Flat-foot 
plates.— 33. Toe post. 

It is obviously desirable that surgeons undertaking the treatment 
of orthopedic cases should not be wholly dependent upon instrument- 
makers. Not only is it important that the surgeon should be able to 
fit and adjust his own apparatus, for except in the larger cities instru- 
ment-makers are not available. The following details are given in the 
hope of enabling surgeons to undertake the measurement and con- 
struction of the simple forms of the common apparatus. In most cases 
the construction of the apparatus below is within the reach of a black- 
smith of ordinary skill, and, with the assistance of a harness-maker to 
do the leather work, the construction of the apparatus described should 
not present any intrinsic difficulty. The forms of apparatus described 
are those which for many years have been in satisfactory use at the 
Children's Hospital, Boston. It need hardly be said that nicety of 
finish and elegance of construction do not add to the efficiency of the 
apparatus, however desirable these qualities may be in making appara- 
tus for persons who are able to bear the extra expense. In order to 
secure uniformity the apparatus described is adapted for the use of a 
child ten years old, and for patients much older or much younger allow- 
ances must be made in the strength and weight of the apparatus. 

1. PLASTER-OF-PARIS BANDAGES 

Plaster bandages are of two types, the quick setting and the slow 
setting. The quick setting are to be used when rapidity of application 

601 



602 ORTHOPEDIC SURGERY. 

is desirable, as in the case of young children, in the application of plas- 
ter jackets in suspension, and in all conditions where for any reason it 
is desirable to save time. Splints made with quick-setting bandages 
are more liable to break, and are not so durable as bandages which take 
more time in setting. The setting of plaster bandages is hastened by 
the addition of salt or alum to the water in which they are soaked, 
about a tablespoonful to a pail of water. It is also influenced some- 
what by the kind of plaster and gauze used. The setting of plaster is 
delayed by the presence of glue either in the sizing of the material used 
or added to the water if desired. 

Material. — The best material to be used for plaster bandages is 
white crinoline, 40 by 40, not sized or starched. 

If crinoline sized with glue is the only kind obtainable, it should be 
washed and dried, to remove the glue, and then cut and rolled into 
bandages. As it wrinkles in drying it is more difficult to cut and to 
handle under these conditions. Crinoline sized with glue sets very 
slowly and is objectionable on that account. Crinoline sized with 
starch costs from six to nine cents a yard. Bandages may be also made 
of coarse cheesecloth, but it is more difficult to cut than the stiffer 
crinoline and on the whole is less satisfactory, but it is cheaper, cost- 
ing from about three cents a yard upward. As the best bandage is one 
that will hold plaster in its meshes and not simply smeared on its sur- 
face, the material used should have a coarse mesh. The best plaster 
splint is not one of alternate layers of cloth and plaster, but one 
in which the layers of cloth are cemented together by plaster of 
Paris. 

Size of Bandages. — For use in the application of bandages for the 
legs and for plaster jackets, the width of the bandages should be from 
three to four inches and the length four yards. The weight of a 
bandage four inches wide and four yards long should be approximately 
from five to six ounces, including the plaster rubbed in. For the cor- 
rection of club-foot in young children, the width of the bandages should 
be two inches and the length not over two or three yards. 

Plaster. — High-grade, finely pulverized plaster, sometimes called 
"dental," is the quickest and best for general use. Ordinary plaster of 
the highest grade sets somewhat more slowly. The plaster should be 
kept in a dry place and preferably should be fresh, and if at all old or 
damp the bandages should be dried in an oven before using. Powdered 
dextrin may be added to the plaster before winding the bandages, in 
the proportion of about one to ten, but it delays the setting, although 
it makes the bandage more durable. Five per cent of Portland cement 
added to the plaster before rolling quickens the setting and hardens the 
bandage, but discolors it somewhat. For general use plaster of Paris 
is the best material. 



PRACTICAL DETAILS OF APPARATUS. 603 

Rolling of Bandages. — Although many forms of machines for roll- 
ing plaster bandages have been described, most surgeons find it more 
convenient to have them rolled by hand. The gauze or crinoline band- 
age is laid flat on the table and a heap of plaster is placed on the table 
near it. A handful of the plaster is then laid on the bandage, and, with 
a flat piece of splint wood or a case knife, this handful of plaster is 
pushed along over the bandage and any excess of plaster thus removed. 
The end of the bandage impregnated with plaster is then rolled, the 
bandage pulled along, and another handful of plaster placed upon it and 
the bandage impregnated in the way described above. 

Bandages should be rolled loosely ; if they are rolled tightly the 
water will not saturate the centre of the bandage. 

Soaking the Bandage. — The bandages should be soaked in a pail 
containing at least six inches of water, sufficiently warm not to chill the 
patient. The bandages are put in the pail resting on their ends, and 
are allowed to remain until bubbles have ceased to come to the surface 
of the water. They are then squeezed by holding them with the hand 
over each end to prevent the escape of the plaster until they are suffi- 
ciently dry not to drip. If they are taken out too soon the plaster is 
not sufficiently softened, and if they are left too long they will set in 
the water. 

Protection of Patient's Skin. — When it is desirable to put on a 
bandage which will not be too bulky and when there is no reason to 
suppose that swelling will occur after the application, the skin may be 
protected by a stocking, by one or two layers of a gauze bandage 
smoothly laid on, or by a layer of stockinet, over which the plaster is 
smoothly applied. When there is reason to suppose that there may be 
swelling, when the patient lives at a distance, or when the bony promi- 
nences are very marked, it will be desirable to protect the skin and to 
guard against harmful pressure by the application of layers of sheet 
wadding smoothly applied in sufficient thickness to guard against press- 
ure. This is especially the case in the application of bandages after 
osteoclasis and in the correction of club-foot. In the application of 
jackets the skin should be protected by putting on, first, a thin sleeve- 
less undervest without buttons, known as " women's ribbed undervests," 
costing about three cents a piece when bought by the dozen ; or a layer 
of stockinet is placed on the trunk and cut off at the desired length. 
Stockinet is sold in tubes of various sizes and the required piece can 
be cut off of the desired length. Bony prominences should be padded 
by felt pads. The felt may be obtained in varying thicknesses from 
one-quarter to three-quarters of an inch, and varies in quality from what 
is known as saddle felting to piano felting, which is the best grade. 
The felt should not be put next to the skin, but put outside of whatever 
is used to protect the skin from the plaster. In the application of plas- 



604 ORTHOPEDIC SURGERY. 

ter jackets it is not necessary or desirable to wind the body in sheet 
wadding. 

Application of Bandages. — Bandages should be applied with a smooth, 
even pressure and uniform tension throughout each turn. They should 
not be put on with too much tension, reverse turns should never be 
made, and there should be no correction in the position of the joint or 
limb after the plaster has begun to set ; otherwise folds will be made in 
the inside of the bandage, which may cause sloughs or impair circula- 
tion. Every portion of each turn should be thoroughly rubbed with 
the hand to unite the layers, and nothing in the application of a proper 
kind of bandage contributes so much to the stability and strength of 
a splint or jacket as vigorous rubbing at every step of the application. 
When bandages are weak or when extra strength is desired, the band- 
age may be folded to and fro, each duplication being smoothed down 
with the hand until the desired number of layers is obtained. This area 
made even is smoothly covered in by circular turns. In general, how- 
ever, six to ten layers of a properly prepared and applied bandage are 
sufficient to give strength. 

The edges of the bandage may be finished by cutting with a knife 
or by turning down over the outside of the bandage one-half of an inch 
of the material protecting the skin, and winding over the turned-down 
part one or two turns of plaster bandage. This leaves the edge of the 
bandage protected by soft material. 

The surface of the bandage may be polished when it is nearly dry by 
rubbing with the wet hand or by rubbing with the plaster paste which 
is found in the bottom of the bandage pail. 

The hands of the surgeon may be protected by the use of thin rub- 
ber gloves, which will prevent roughness of the skin caused by the use 
of plaster of Paris. A properly applied plaster bandage should be 
sufficiently dry in five or ten minutes from the time that the applica- 
tion has ceased. 

In the case of plaster bandages to the leg which are inclined to slip 
down over the ankles and give trouble, they may be anchored in place 
by the use of a strip of sticking plaster, three or four feet long and one 
inch wide. This sticking plaster is applied to the outside of the leg 
from the knee down under the sheet wadding. A few layers of plaster 
bandage are then put on, and the strip of sticking plaster which pro- 
jects below the lower edge of the bandage is then turned up and incor- 
porated in the bandage. 

Removal of Bandages. —If it is desired to remove the bandage, the 
plaster should be moistened by means of a medicine-dropper with 
either water or a weak solution of acetic acid. When the plaster is wet 
it can be cut with ease by a sharp knife. The most convenient appara- 
tus is either a knife known as a shoe knife or a knife with a concealed 



PRACTICAL DETAILS OF APPARATUS. 605 

blade known as the electrician's knife. It is not desirable to make the 
cuts toward the patient's skin, but parallel to or away from it. After 
the application of a plaster jacket, if for any reason it is feared that 
there may be constriction of the circulation, it should be cut down in 
the front immediately after application, so that it may be sprung open 
in case of emergency. If sinuses are to be dressed, or if for any rea- 
son it is desirable to remove the pressure from a given point, windows 
may be cut in the bandage. It is also possible by means of two cuts on 
the opposite sides of a bandage to remove a lid, through which the joint 
or limb may be inspected, and which can be replaced. This lid can be 
held in place by bandaging with a wet gauze bandage. When bandages 
are likely to be worn for a long time, and especially in the application of 
spica bandages to the hip, it is desirable to leave a strip of soft gauze 
inside of the bandage for cleansing purposes. The two ends of this 
above and below the bandage should be left sufficiently long to be fast- 
ened together. By pulling this strip of gauze to and fro, crumbs, etc., 
are removed. The indications for the early removal of a plaster band- 
age are the presence of constant pain, an offensive smell, or the detec- 
tion of a serous discharge staining the outside of the jacket. These 
signs point to harmful pressure or the formation of slough. The time 
which a plaster jacket or bandage should be worn varies, of course, 
with each case. 

2. CELLULOID BANDAGES. 

Celluloid jackets or bandages are light, clean, and fairly durable. 
They are not dangerous when exposed to heat, and if touched with a 
lighted match burn with about the same rapidity as sheet wadding. 
They cannot be applied directly to the patient, but must be made on a 
dry plaster cast of the limb or trunk. To manufacture this the plaster 
bandage is applied and immediately removed, fastened together, one 
end closed, and the side not stopped is filled with a plaster-of-Paris 
cream. The mould is then removed and the cast smoothed, dried, and 
shellacked. For the application of celluloid splints a celluloid paste is 
made by dissolving celluloid chips in acetone or wood alcohol. This 
paste, which should be about as thick as ordinary mucilage, is used as 
a paint to cement together and harden the layers of some cloth placed 
over the cast. This cloth may consist of cheesecloth bandages, stock- 
inet, or undervests similar to those described for plaster jackets. Each 
layer of cloth receives several coats, each one of which is allowed to dry. 
When the cloth material takes up no more celluloid, another layer is 
added and painted in the same way. From six to ten layers of the kind 
of undervests described for plaster jackets are required to make a dura- 
hie celluloid jacket. The thickness of the bandage in each case must 
he a matter of individual judgment. After a sufficient thickness has 



6o6 



ORTHOPEDIC SURGERY. 



been reached it is most important to leave the bandage or jacket on the 
cast until it is thoroughly dry inside and out ; otherwise it will warp 
when taken off. When it is thoroughly dry it is cut and removed, the 
inside finished with a fresh painting of celluloid, the edges are trimmed 
and bound with leather, the jacket is perforated by holes throughout, 
and leather straps one inch wide, containing studs or lacings from one 
to two inches apart, are sewed to the jacket, one inch or more from each 
side of the cut extending its entire length. For the use of plates and 
splints, for the forearm, for instance, sheet celluloid or pyroline may be 
used, of a size from one-thirty-second to one-quarter of an inch thick, 
which is softened in hot water and shaped to the cast by binding it on 
with rubber tubing wound on the stretch, the cast and celluloid being 
immersed in boiling water until the celluloid is shaped to the cast. 
The edges should be smoothed off with a file, and the surface of the 
celluloid may be polished if desired. The white variety of celluloid is 
more brittle than the transparent. 



3. LEATHER SPLINTS AND JACKETS. 

Moulded leather splints and jackets are made from oak-tanned Eng- 
lish leather, which should not be "filled" or "stuffed." The finished 
leather is not useful for this purpose. The leather is cut of the desired 

pattern and softened by soaking in 
water. When it is thoroughly flex- 
ible it is stretched over a plaster cast 
of the limb or trunk and made to 
conform to all the curves of it. 
This may be accomplished by fasten- 
ing one edge and hammering or 
pressing it to fit the hollows and fast- 
ening it by tacks on the other edge 
when it is properly moulded, or it 
may be wound on to the cast by 
means of a rope encircling it in close- 
ly fitting turns. After being shaped 
it is allowed to dry on the cast and 
removed. It will retain the shape 
which it assumed when wet, if it is 
thoroughly dry. If it is wished to 
stiffen the leather in order to secure 
a firmer support, especially in the case of jackets, the moulded leather 
splint is painted with hot bayberry wax until it ceases to absorb it, and 
it is then allowed to dry. The bayberry wax discolors the leather some- 
what and gives a dull finish. If it is desired to have a highly polished 




FlG. 546.— Stiff Jacket Split and Laced. 

(Children's Hospital Report.) 



PRACTICAL DETAILS OF APPARATUS. 607 

and non-absorbent surface, the jacket is now painted with a solution of 
shellac inside and outside and allowed to dry thoroughly. Several 
coats are necessary. This forms a fairly durable finish, which in time 
softens somewhat under the influence of heat and perspiration and 
pressure. Jackets and splints finished in this way do not need to be 
reinforced with steel unless a great deal of pull or pressure is coming 
upon them. If desired they can be reinforced with strips of steel fast- 
ened on the outside and riveted to the jacket. Such steels may be pro- 
tected from rust by nickel-plating or may be covered with kid sewed 
over them. Jackets and splints should be provided with the leather 
lacings mentioned in speaking of celluloid jackets. 

4. ANTERO-POSTERIOR SUPPORT FOR POTT'S DISEASE. 

The apparatus consists of four parts: (a) Two uprights, .(b) A bot- 
tom piece, (c) Tzuo shoulder pieces, (d) One or two cross bars. 

(a) The uprights reach from the seventh cervical vertebra to one 
inch below the posterior superior spine of the ilium. They should run 
on each side of the spine over the transverse processes. They are 
curved to fit the tracing of the spine made with the child lying on the 
face and taken over the transverse processes of the spine. Some alter- 
ation in this curve may be necessary to suit the standing position. 
For a child ten years old the uprights should be made one-half of an 
inch wide and about one-sixteenth of an inch thick, being made of No. 
8 gauge cast steel. There should be a pad plate on each upright, reach- 
ing from the level of the highest point of the deformity to two vertebrae 
below the lower part of the deformity. They should be of spring steel 
gauge No. 16, three-quarters of an inch wide, shaped to fit the curve of 
the upright and also curved from side to side if necessary to fit the lat- 
eral contour of the deformity ; otherwise they may bear only on the 
inner edge. They are fastened to the upright by a rivet at their top 
end, and if increased pressure is desired they may be wedged forward 
from the upright. They are covered with thick, firm felt or with 
leather. They may also be made of celluloid or hard rubber accurately 
fitted to the contour of the deformity, but the latter are difficult to 
make comfortable and adjust. 

(b) Bottom Pieces. — The bottom pieces consist of two vertical pieces 
behind and to the inner side of the trochanter. These are joined above 
the posterior superior spines of the ilium by a transverse piece rounded 
posteriorly to fit the contour of the sacrum and not strike bony promi- 
nences. The whole bottom piece should thus consist of one piece, 
shaped like an inverted U, finished below with circular plates, the size 
of a fifty-cent piece, padded with felt, covered or not with leather. The 
vertical measure for the bottom piece should be taken from above the 



6o8 



ORTHOPEDIC SURGERY. 



posterior superior spine to one inch above the level of the tuberosity of 
the ischium. The lateral measurement consists of the distance between 
the post-trochanteric fossae. The material is the same as the upright. 
(c) Two Shoulder Pieces. — The shoulder pieces are two in number 
and separate. They are of the same width as the upright, are made of 




Fig. 547— Antero-posterior Support for Pott's Disease. 

a flexible steel, No. 14 gauge, one-sixteenth of an inch thick, and are 
riveted to the top of each upright. They are bent outward on the flat 
at an angle of about forty-five degrees, and are also curved downward to 
conform to the curve of the shoulder. They should reach from the top 
of the upright to the forward edge of the trapezius. The measurement 
is the distance from an inch or more below the top of the upright to the 



PRACTICAL DETAILS OF APPARATUS. 



609 



forward edge of the trapezius. The curve outward begins at the top of 
the upright. 

(d) Cross Bars. — These are flat transverse bars. The first, in 
length is slightly less than the breadth of the trunk at the axillary line. 
It is fastened to the uprights at a level slightly below that of the axilla, 
and if necessary should be bent backward in its outer part so as not to 
bear on the scapulae. The measurement is as given; the material 
should be the same width as the upright, made of sheet steel, gauge 
No. 14. A second cross bar may be added two or three inches below 
the one described and slightly shorter than the other, and in length is 
less than the breadth of the trunk. It can be omitted in thin patients. 
These pieces are fastened to the upright by stout rivets, the edges are 




FIG. 548.— Apron for Use with Antero-posterior Spinal Support. 

smoothed and rounded, and all the parts should be fastened to the pos- 
terior surface of the uprights. 

Buckles. — Brass buckles, seven-eighths of an inch in width, should 
be fastened on leather tabs and riveted to the brace by means of holes 
drilled in it. There should be one pair at the bottom of the U piece, 
and, if perineal straps are to be used, two pairs. A pair should be 
fastened to the top of the U piece, and in larger children another pair 
to the middle. There should be a buckle at each end of each cross 
bar. In place of a buckle at the end of the shoulder piece, which is 
unsightly and causes the clothes to stand away from the shoulders, a 
short leather strap should be fastened on the top end of each upright, 
and to these straps should be attached the axillary straps and another 
one to be described, which is used in certain cases. 

Apron. — The brace is held to the body and made efficient as a lever 
by means of an apron covering the anterior surface of the body and 
fastened to the brace at several levels. This apron is made of stout 
39 



610 ORTHOPEDIC SURGERY. 

cloth known as Hadley sheeting. The width of this is from the mid- 
dle line of one side of the body to the middle line on the other ; roughly 
it might be described as ending at the anterior axillary line. Above it 
should not reach as far up as the top of the sternum ; below it should 
extend to the symphysis pubis. The upper corners are cut out in front 
of the shoulders in a sweep, concave downward and inward. The 
apron is smoothly fitted to the curves of the body, especially of the 
abdomen, by means of gores or gussets at the edges if necessary. 
Wrinkling may be prevented by stiffening the apron at the waist with 
corset steels or bones. The edges of the apron are finished by one-half 
of an inch hemming. 

Finish of Brace. — When the splint is finished it should be nickel- 
plated, blued, or japanned to prevent rusting. The skin of the back 
should be protected from the brace above and below by a square of felt 
or leather loosely attached at the top and at the U-piece below. This 
should cover only the points of contact with the skin. The shoulder 
piece, if projecting beyond the uprights, should be covered with moose 



FIG. 549.— Taylor's Chest Piece. 

hide, thick chamois, or felt. If the anterior surface of the brace rusts, 
which it should not do if nickel-plated, the clothes of the patient may 
be protected from rust by laying a pad of felt under the brace. 

Straps from the Apron to the Brace. — These are made of webbing 
tape, one inch wide, costing four cents a yard. A strap on each side at 
the level of the axilla is sewed to the edge of the apron and passes 
around to fasten into the buckle at the end of the upper cross-bar. 
There should be a strap on each side on a level with the top of the U- 
piece to fasten to the buckle there. There should be a strap on each 
side at the bottom of the apron to fasten to the buckle at the bottom 
of the U-piece. In larger children, where there is a buckle in the mid- 
dle of the U-piece, there should be an extra pair of straps on a level 
with these buckles. Two longer straps, one carrying a buckle, should 
be sewed to the middle of the apron, and these pass around the back 
outside of the brace and are buckled together, forming an additional 
strap. At the top of the brace an axillary strap should be sewed on 



PRACTICAL DETAILS OF APPARATUS. 



611 



each side to the leather strap fastened to the top of the cross-bar. 
These axillary straps pass around the shoulders and through the axilla 
to the buckle in the end of one of the cross-bars from the tip of the 
shoulder-piece. To the leather on the top of the shoulder-piece is also 
sewed a strap on each side, which passes to buckles sewed at the top 
edge of the apron. These straps should be padded by being wound 
with sheet wadding and covered with canton flannel or a soft leather. 
Perineal straps padded in the same way, one on each side, should pass 




FIG. 550.— Oval Ring Head Support Added to tee Antero-posterior Support. (See Fig. 76.) 

from the lower end of the apron at a point opposite the top of the fold 
in the groin, to a buckle to the bottom of the U-piece. They are an im- 
portant addition to the security of the brace and are essential in disease 
of the lower part of the spine or when the brace tends to ride up. 
They are not to be used in connection with head supports. 

A leather gorget may be used for the upper part of the chest when 
it is desirable to prevent the pressure on the chest from the top of the 
apron. It is used independently of the apron and the top of the apron 
is cut away. When this is done the axillary end of the leather gorget 



612 ORTHOPEDIC SURGERY. 

should be finished with webbing straps, one on each side, which are 
fastened to extra buckles placed at the top of the U-piece of the brace. 
Head supports are needed in connection with the antero-posterior 
support or the plaster jacket in Pott's disease of the upper part of the 
spinal column. 

5. OVAL RING HEAD SUPPORT. 

This is to be worn in connection with the antero-posterior spinal 
support, and consists of (a) an oval ring, {b) a spindle, and (c) a socket. 

(a) The oval ring should extend from the occiput behind to the tip 
of the chin in front. In width it is slightly wider than the distance be- 
tween the angles of the jaw. It is hinged at the angle of the jaw at 
one side to open in a horizontal plane, and on the opposite side at the 
same point is fastened when closed by a ring clasp. It is made of one- 
quarter of an inch spring steel. 

The antero-posterior diameter is from just below the occipital pro- 
tuberance to the tip of the chin; the lateral diameter is the width be- 
tween the angles of the jaw, to which should be added one-half of an 
inch or less on each side. 

At the anterior end of the oval ring there should be a plate of hard 
rubber or celluloid moulded to the shape of the chin. This is riveted 
to a sheet-tin bridge, three-quarters of an inch in width and one and 
one-quarter inches long, soldered to the front of the ring. An occipital 
pad is required of hard rubber or thick leather, fastened to the inside 
of the posterior part of the ring and slanting backward to give support 
to the occiput. This pad, made of sheet steel covered with leather, 
should be approximately shaped to the contour of the back of the head. 
To the middle of the back of the ring is riveted a piece of steel suffi- 
ciently thick to be pierced with a vertical hole, into which is inserted the 
top of the spindle which connects the ring with the top of the brace 
and permits horizontal rotation. 

(b) Spindle. — The steel spindle which connects the ring with the 
brace below fits into a socket riveted to the two uprights of the brace. 
The spindle should be bent in such an antero-posterior curve that when 
the brace is applied the oval ring should touch the occiput and chin at 
a proper angle. The spindle is prevented from dropping down in the 
socket of the brace by a set screw passing through the back half of the 
socket. By the use of this screw the spindle may be raised or lowered 
as desired. 

The length of the spindle is a distance from a point just below the 
occipital protuberance to the point on the uprights selected for the 
socket. The spindle is forged from three-eighths of an inch machine 
steel, and in its lower part is one-quarter of an inch wide and thick, 
being flattened on the anterior surface and curved on the posterior. In 



PRACTICAL DETAILS OF APPARATUS. 



613 



its upper third it becomes circular, and terminates above in a vertical, 
circular pin, one-sixteenth of an inch in diameter, fitting accurately into 
the socket at the back of the oval ring. As a guide to the shape of the 
spindle, a tracing should be taken with a strip of lead in the middle line 
at the back, running from the occiput to the point where the socket is 
to be attached to the uprights. 

(r) Socket. — The socket consists of a flat steel bar, riveted at each 
end to the uprights of the brace. In the middle it is sufficiently thick 
to allow a hole to be drilled in it from above downward, through which 
passes the lower part of the spindle. This piece, of machine steel, 
should be one-half of an inch wide and three-quarters of an inch thick. 
The dimensions of the hole for the spindle are the same as those given 
for the lower part of the spindle, which fits closely into the hole. The 
spindle is prevented from slipping down by two set screws, which turn 
in threads drilled in the posterior half of the socket where the spindle 
passes through. The parts described are finished in the same way as 
the rest of the brace. 



^^ 



6. ANTERIOR HEAD SUPPORT. 

The anterior head support is to be attached to the antero-posterior 
support or the plaster jacket. It consists of (a, b) tivo pieces of wire, 
and (c) an occipital piece of steel. 

{a) The chest and shoulder piece is a U-shaped piece of wire bent 
to rest on the shoulders and on the 
chest, not bearing on the clavicles. 

The U-piece which is applied to 
the chest and shoulders is meas- 
ured from the level of the xiphoid 
cartilage to one inch posterior to the 
anterior border of the trapezius. 
These strips are vertical. The width 
of the bottom of the U-piece is 
the horizontal distance between 
the middle of the clavicles. It is 
bent to follow the lateral contour 
of the chest, and from below up- 
ward lies closely against the chest 
and shoulders, but is bent out over 
the clavicles. 

(b) The other piece of wire, the chin-piece, is bent to follow the 
outline of the chin and the ramus of the jaw. The posterior ends of 
the chin-piece are bent vertically downward just back of the ramus of 
the jaw, and welded or soldered to the chest-piece at points posterior to 
the clavicle on each side. 




FIG. 551. — Anterior Head Support. (See 
Fig. 77.) 



6 14 ORTHOPEDIC SURGERY. 

(c) The occipital piece consists of a strip of cast steel wire, one- 
quarter of an inch thick, running horizontally behind the head and bent 
around the wire upright on one side to form a hinge and secured to the 
opposite wire upright by a hook catch made by bending over its end. 

The length of .the anterior horizontal portion is the distance from 
just behind the ramus of the jaw to the tip of the chin. Its width is 
the distance between the outer surface of the mastoid processes plus 
one-half of an inch or less on each side. The height of the vertical 
portion of the chin-piece, where its posterior ends are bent down to 
unite with the shoulder-piece, is measured from the tip of the ear to 
the point where the highest portion of the shoulder-piece passes over 
the shoulder. This vertical portion slopes outward from the ramus of 
the jaw to the shoulder part of the U-piece. The measure of the occi- 
pital part of the brace is the distance between the tips of the ears 
measured as a curve, not touching the skin, at a level just below the 
occipital protuberance. 

To prevent chafing of the skin, pads are attached under the tip of 
the chin, as described in the oval ring. The occipital piece is padded 
behind with thick felt covered with leather. To the portions of the U- 
piece of the brace passing over the shoulder and across the sternum are 
soldered strips of thick machine steel, three-quarters of an inch wide 
and one-quarter of an inch thick, curved to fit the brace, perforated at 
their edges with small holes, so that there may be stitched to the pos- 
terior surface of these steel pieces felt pads covered with chamois or 
kid. The material used for constructing this head-piece is cast steel, 
one-quarter of an inch in diameter. 

The support is fastened to the back brace by means of strips of 
webbing, one inch wide, riveted to the upper part of the U~piece. 
These straps, which should be padded, pass over the shoulders and are 
fastened to buckles riveted to the upper ends of the antero-posterior 
support. Similar webbing straps are also attached to the lower angles 
of the U-piece and pass horizontally around the sides of the chest, to 
be fastened to buckles attached to the middle of the antero-posterior 
support. 

If it is desired to give greater security to the head, upright strips of 
steel may be attached to the posterior part of either of the forms of 
support just described, the oval ring or the antero-posterior support. 
These strips are bent to conform to the posterior contour of the head, 
and pass upward one inch behind the mastoid processes to the level of 
the parietal eminences. They are made of spring steel, one and one- 
quarter inches wide and one-sixteenth of an inch thick, forming a 
padded plate at the top riveted on to the upright. The length of the 
upright, made of one-quarter of an inch round cast steel, is the distance 
from the horizontal ring to the parietal eminence. They are provided 




PRACTICAL DETAILS OF APPARATUS. 615 

at their upper ends with buckles, which are riveted to them, which 
serve to secure a padded webbing strap passing forward round the 
forehead from one upright to the other. They are also provided at the 
level of the mastoid processes with a buckle facing inward on each up- 
right, which serves to secure a supporting strap passing behind the oc- 
ciput. The tightening of these straps steadies the head, and, with the 
chin-piece, holds it firmly. 

7. THOMAS COLLAR. 

The original Thomas collar consisted of a strip of calf skin folded on 
itself to the depth of from four to six inches, the two free ends being 
stitched together in an irregular curved line. In the centre of the por- 
tion to be placed under the chin the stitching 
was from four to six inches below the upper 
border. At the point below the ear the ®p 
stitching was two inches from the upper bor- 
der. At the posterior portion the lower 
border of the stitching was three inches be- 
low the upper border. Sawdust was pressed FlG " ^s^pi- *8 0°' 
in between the folds of leather held below 

by the stitching and above by the folded top of the leather. Straps 
and buckles were attached to the posterior portion of the collar stitched 
around the neck. A greater or less amount of sawdust was packed into 
the cavity, in order to increase or diminish the amount of support. 
This collar, which can be made by any saddler, is somewhat awkward 
in shape but readily made. As a substitute for this, a collar stock can 
be made of stiffened leather similar to what is used for leather jackets, 
reinforced by steel or phosphor bronze and padded with felt. The 
length of the collar or stock should be sufficient to encircle the neck 
and fasten behind without overlapping. 



8. QUADRILATERAL BACK BRACE. 1 

The design of this brace is to combine with the antero-posterior 
leverage action of the Taylor back brace the power of checking rotation 
obtained in the plaster-of-Paris jacket. The entire upper chest is left 
free from the pressure of the apron, and the shoulder girdle is used as 
a point of counter-pressure for the axillary straps. This is made pos- 
sible by the fastening of the scapulae under the widely separated up- 
rights, which restrict their motion upon the thorax within very narrow 
limits. It consists of (a) a pelvic band; (b) two uprights; (Y) a top 
bar; (d) a pad plate bar; (e) an apron. 

1 John Dane: Trans. Am. Orth. Assn,, xiii., 70. 



6i6 



ORTHOPEDIC SURGERY. 



(a) The pelvic band is made of No. 15 gauge sheet steel, and is bent 
to fit the curve of the pelvis, circling it behind at a point just above 
the trochanters. Its anterior ends reach to the anterior superior spines. 
(p) The uprights, made of No. 12 gauge cast steel, and riveted to 
the pelvic band a little outside of the posterior superior spines. They 
extend upward to one-half of an inch above the spines of the scapulae. 
To their ends are riveted the descending arms of the top bar. These 
uprights are bent so as to follow the curve of the flanks, but not to 

rest upon the skin until they pass 
over the scapulae, from which point 
they should press upon the skin 
when the shoulder-straps are tight- 
ened. 

(V) The Top Bar. — This is made 
of the same size of metal as the 
uprights. Its length is the diameter 
of the back, taken from one-half of 
an inch inside the glenoid rim of 
the scapulae, when the shoulders 
are pulled backward. Each end of 
this bar is bent at a right angle 
downward and continued for one 
inch. To these descending arms 
the upper extremities of the up- 
rights are riveted. 

(d) The Pad-Plate Bar.— This 
is a horizontal bar, No. 14 gauge 
sheet steel, fastened to the uprights 
by means of a flat-headed screw at 
the level of the kyphos. Its central 
portion is curved sharply backward 
so as to clear the spinous process of 
the vertebrae. On the slope of this 
curve on each side are riveted the 
pad plates. These are flat strips of No. 18 gauge sheet steel, one-half 
of an inch wide and from one and one-half to three inches long. The 
distance between them is enough to insure their pressure falling upon 
the transverse processes of the vertebrae. To facilitate adjustment of 
the pad-plate bar the opening for the screws that hold its ends to 
the uprights is made in the form of slits, one-half of an inch in 
length. 

Three buckles are riveted to the uprights, one on each side, the 
upper one just below the axilla, the others equally spaced below. One 
more pair of buckles are riveted to the ends of the pelvic band. One 




FlG. 553 — Quadrilateral Back Brace. 



PRACTICAL DETAILS OF APPARATUS. 617 

end of a padded strap is riveted to the outer end of the top bar on each 
side. 

The frame of the brace is wound with canton flannel or covered on 
the side next the skin with leather. Each pad plate has a felt pad, 
three-eighths of an inch thick, sewed to its anterior surface. These can 
be frequently changed as occasion may arise. 

(e) The Apron. — This is cut from sole leather, one-sixteenth of an 
inch thick. Its length extends from the level of the ensiform to the 
top of the pubis in the median line ; from the level of the ensiform to 
the anterior superior spines on the sides. Its width is the diameter be- 
tween the anterior spines. Straps of webbing are sewed to this on each 
side opposite the lower buckles on the brace, the upper pair of buckles 
taking the ends of the padded straps that come from the top bar of the 
brace. 

Quadrilateral Back Brace with Head Support. 

The brace is similar to that just described, with the addition of a 
second horizontal bar connecting the uprights from one to two inches 
below the top bar. In cases of very high deformity the pad-plate bar 
can be made to take its place. 

The head support consists of: (a) Two uprights; (&) the occipital 
strap; (c) the frontal strap. 

{a) The uprights. Starting as flat forged steel bars, one-half of an 
inch wide and one-eighth of an inch thick, from one inch below the 
second horizontal bar, they are carried straight upward to a point one 
inch below the occiput ; then as round rods they are curved upward and 
outward to a point one inch above and one-half of an inch behind the 
ear ; then forward close to the head as flat bars to the level of the pos- 
terior part of the forehead. As they pass around the occiput behind 
they are one-half of an inch from the head. These uprights pass 
through guides riveted to the posterior surface of the top and second 
bars of the brace. The guides on the second bar are perforated with 
holes and finished with screws for holding the uprights in position. 
The width between the guides should be a little less than the trans- 
verse diameter of the patient's neck. The horizontal flanges are cov- 
ered with leather on their inner sides where they grasp the head. A 
buckle is riveted to the anterior end of each horizontal flange. 

(d) The occipital strap is made of a thin strip of brass, one-quarter 
of an inch wide, covered with calf -skin. On one end it is prolonged 
forward for one-half of an inch as a right-angled arm. This is riveted 
to one of the uprights at the angle where it becomes horizontal. Its 
other end is free. This strap is padded on its inner side with thin felt 
and covered with leather. On the free end this leather is prolonged as 



618 ORTHOPEDIC SURGERY. 

a strap and passes through a buckle riveted to the outer side of the 
other upright at the angle where that becomes horizontal. 

(c) The frontal strap is made of calf -skin, one inch wide where it 
crosses the forehead, rapidly tapering to the diameter of the buckles 
that have been riveted to the horizontal arms of the uprights. Each 
end of this strap is punched with a series of holes for the tongue of the 
corresponding buckle. 



9. THE GAS-PIPE BED FRAME. 

The gas-pipe bed frame is of a rectangular form and is made of 
ordinary gas pipe, the size of the gas pipe being governed by the size 
and weight of the patient. What is known as "quarter-inch" pipe is 
sufficiently large for children, and three-eighths of an inch pipe for 
adults of moderate weight. 

Four pieces of gas pipe are threaded at their ends for one inch, and 
are attached to each other at the four corners by four elbows. The 






Fig. 554.— Gas-Pipe Frame. 

length of the frame is the height of the patient, with the addition of 
four inches. The width of the frame is the distance between the axil- 
lary lines or a little less. The frame is covered with stout cotton cloth, 
generally doubled. This cover should be a little short of the full 
length of the frame and one and three-quarters times as wide. This 
passes over the front of the frame and around its sides, and is secured 
behind by webbing and buckles, which are sewed to its under side at 
proper intervals or is laced by a cord stitched through the edges by 
means of a sailor's needle. To protect the cover from wrinkling two 
tapes are run from the top and two from the bottom of the cover to 
the top and bottom of the frame. The cover should be smoothly 
stretched on the frame and should lie without wrinkling. When the 
patient must not be lifted for the use of the bed pan, the covering is 
opened by two cuts intersecting at a right angle opposite the pelvis. 
The cut flaps are sewed back to the back part of the covering, and the 
borders of the cover at the hole are protected by rubber sheeting. 
The cover is easily renewed when stretched or soiled. In heavy pa- 
tients, to prevent the sides of the frame from being pulled together, 
they are braced apart by a flat strip of machine steel, three-quarters of 



PRACTICAL DETAILS OF APPARATUS. 619 

an inch wide and one-quarter of an inch thick. This strip is bent at 
the ends to hook over the pipe at the sides of the frame. 

If it is desired to hold the spine in a position of hyperextension, the 
sides of the bed frame may be curved upward opposite the deformity 
to any desired extent. This curve may be a gradual one or a section of 
the frame may be elevated by an abrupt curve above and below it. 

10. TRACTION HIP SPLINT. 

The traction hip splint consists of : (a) A horizontal pelvic band ; 
(b) an outside upright ; and (c) two or three posterior bands behind the 
thigh and calf. 

(a) The pelvic band is made of one piece of flat steel curved in the 
shape of a U, which passes along the front of the pelvis, around the side 
on which is situated the diseased hip, and then passes along the poste- 
rior surface of the pelvis. The anterior part of the pelvic band forms a 
curved right angle with the outer surface of the band, which is some- 
what flattened, but where the outer part of the band joins the posterior 
part the angular curve is rounded and is not so sharp as at the anterior 
angle. The measurements of the pelvic band are as follows : The an- 
terior half extends from the point at the middle of the outside of the 
thigh just above the trochanter to a point just beyond the opposite an- 
terior superior spine of the ilium. The posterior half is one inch longer 
than the anterior half, and is bent in a more gradual curve, as has been 
said. The pelvic band is made of tire steel, No. 8 gauge, and one inch 
wide. It is forged so that the anterior and posterior parts are parallel 
to each other in the vertical plane, and the free ends are rounded. The 
pelvic band is fastened to the upright at an inclination of twenty de- 
grees from a right angle, the posterior part being higher than the ante- 
rior. The anterior and posterior arms of the pelvic band should be 
separated by a distance of one inch greater than the antero-posterior 
distance between the anterior and posterior superior iliac spines. The 
pelvic band should form a right angle in the lateral plane with the up- 
right. 

Buckles are placed on the pelvic band, two in front and two be- 
hind, to hold the perineal bands which furnish counter-traction to the 
extension pull downward. At the back they are situated just posteri- 
orly to the trochanters, one on each side. The perineal bands pass 
forward at the side of the perineum to buckle on the anterior arm, 
one at each side of the median line. These buckles should be placed 
as close together in front as is possible without interfering with the 
genitals. Another buckle is fastened to the anterior end of the pelvic 
band, to which is fastened a strap passing from the posterior end. The 
pelvic band is padded on the inside with a strip of felt and covered with 



620 



ORTHOPEDIC SURGERY. 



leather stitched at the edges. The inside of the band should be cov- 
ered with sheep-skin and the outside with morocco leather or calf-skin. 
The buckles are riveted on through the leather and are on the outside 
of it. The leather which covers the pelvic band is made long enough 
to pass beyond the end of the posterior arm of the splint, and, passing 
around the outside of the pelvis of the patient, is buckled into the 




Fig. 555.— Long Traction Hip Splint. 
(See Figs. 119 and 122.) 



Fig. 556.— Side View of the Long 
Traction Appliance. 



buckle on the anterior arm of the pelvic band. This may be done by 
means of a webbing strap, seven-eighths of an inch wide, passing into 
a seven-eighths-of-an-inch buckle, or by means of a strap of leather 
riveted to the leather of the pelvic band. This leather strap should 
be one and one-quarter inches wide. The upright is finished by being 
nickel-plated, blued, or japanned. 

(b) The upright runs on the outside of the leg, from a point on a 
level with the anterior superior spine of the ilium to a point two and 
one-half inches below the bare heel. It should be straight, except in 
the case of very fat patients, when it should bend outward in its upper 
third to follow the curve of the hip. The bottom of the upright is 
flattened from side to side for a distance of three and one-eighth 
inches. After being flattened at this point it should measure five-eighths 



PRACTICAL DETAILS OF APPARATUS. 621 

of an inch wide and one-quarter of an inch thick. It is then turned in 
at a sharp right angle to the upright for a distance of two and one- 
half inches, and the part coming next to the ground is forged flat. 
After running inward at a right angle to the upright for two and 
one-half inches, the extreme end is turned up at a right angle, running 
up from the bottom of the foot-piece where it touches the ground 
a distance of five-eighths of an inch. This constitutes the bottom 
piece of the splint, to which a windlass arrangement is attached. This 
consists of a spindle, three inches long and one-quarter of an inch in 
diameter, passing through holes drilled in the upright at a point one- 
half of an inch from the bottom of the splint to a corresponding hole in 
the turn of the inner part of the foot-piece. This spindle is fastened 
in place by a pin passing through it on the outside of the part project- 
ing up from the inside of the foot-piece. It projects beyond the outer 
surface of the upright for a distance of three-eighths of an inch. Next 
to the upright and outside of it is fastened upon the spindle a ratchet 
wheel, one-half of an inch in diameter, which is controlled by a spring 
and stop, one and one-eighth inches in length, fastened to the upright 
above it by a pin. The end of the spindle terminates in a square end- 
piece fitted to a clock key. By means of this attachment it can be 
turned only in one direction. The spindle is partially split at its middle 
for the insertion of webbing straps. 

The upright at its top is fastened to the pelvic band in one of two 
ways. In small children, where there is not very much strain, the 
upper end of the upright is flattened out, forming an angle of twenty 
degrees with the upright and curved to lie close to the pelvic band. In 
its flattened part three holes are drilled, and corresponding to them 
three holes are drilled in the pelvic band, and by means of these holes 
the pelvic band is fastened to the upright by three strong one-eighth- 
of-an-inch rivets. For large patients, where greater strain is liable, a 
stronger connection is necessary. In this case a heavy pelvic band is 
necessary, and the upright is not flattened at its top but is left square. 
A short steel strip is then forged in such a way that it passes along the 
pelvic band in front of the upright for a distance of one inch. It then 
curves out and round the upright and back to the pelvic band, which it 
follows for one inch posterior to the upright. In front of the upright 
and back of it holes are drilled in this strip, and holes are drilled in the 
pelvic band opposite to them, through which stout rivets are passed. 
A hole is also drilled through the strip of steel passing outside the up- 
right, through the upright, and through the pelvic band, and through 
this hole another rivet is passed, contributing greater stability. The 
upright should be made of one-inch quadrilateral machine steel. If the 
child is not to walk in the splint, a piece of quadrilateral steel, three- 
eighths of an inch in diameter, may be used. 



622 



ORTHOPEDIC SURGERY. 



(c) Posterior Bands. — To fasten the leg to the splint, two or three 
posterior curved bands are necessary. In young children two are suffi- 
cient; in older children and adults three are necessary. If two bands 
are used, one should be placed below the middle of the thigh and the 
other at the upper, third of the calf. If three bands are used, one is 
placed above the middle of the thigh, one at the lower part of the thigh, 
and one at the upper third of the calf. The circumference of these 
bands should be half the circumference of the thigh or leg at a corre- 
sponding level. The curve should form the posterior half of a circle 





Fig. 557- 



-Apparatus for Extension. 
Prize Fund Essay.) 



(Fiske 



FIG. 558.— Windlass and Ratchet Appliance 
for Extension. (Fiske Prize Fund Essay.) 



and should be made of sheet steel of No. 14 gauge and one inch wide. 
They are fastened to the inner side of the upright and should project 
one-half of an inch beyond the anterior edge of the upright. By means 
of an arrangement similar to that described for fastening the pelvic 
band to the upright in heavy patients, these are fastened to the upright, 
except that no rivet is passed through the upright and that screws in- 
stead of rivets are used to fasten the two ends of the encircling piece 
of steel to the calf or thigh band. By tightening these screws the 
curved band is fastened firmly in place, and by loosening the screws it 
can be moved up and down on the upright. 



PRACTICAL DETAILS OF APPARATUS. 



62 



The calf bands are padded on the anterior surface with felt and cov- 
ered with calf or ooze leather stitched on the edges. On the inner end 
of each curved band a webbing strap is riveted, to pass around the front 
of the leg and fasten into a buckle, riveted on the end of the calf or leg 
band close to the splint. 

Perineal Bands. — Perineal bands are made of webbing padded in 
their middle half by felt covered with canton flannel, or they are made 
.of leather padded with felt and covered with moose hide. The cover- 
ing of the perineal bands should be stitched together on the under side 
of the strap, so that the stitching will not come in contact with the skin 
of the perineum where pressure would make it uncomfortable. 

11. CONVALESCENT HIP SPLINT. 

The traction hip splint may be changed to a protection splint suita- 
ble for use in convalescence as follows : Instead of ending below in the 
traction foot-piece described above, the upright is cut three inches 
above the lower end, and there is welded to the upright a piece long 
enough to extend two inches below the sole of the foot, which below is 




o 



Fig. 559.— Detail of Foot-piece of Convalescent Hip Splint. 



expanded into a bulbous tip, three-quarters of an inch in diameter, con- 
taining in its centre a hole, in which is inserted a plug of rubber, which 
is fastened into the bottom of the foot-piece. 

This crutch tip serves to receive the impact of the weight in walk- 
ing, and should be of such a length that, while the ball of the foot may 
be used in walking, the heel is prevented from touching the ground. 
The length of the upright under these conditions should be the dis- 
tance from the anterior superior spine of the ilium to the bottom of the 
heel of the shoe, when the foot is at a right angle, plus one to one and 
one-half inches. In case it is desired to have the splint made so that 
its length may be adjusted to the growth of the child, this may be done 



624 



ORTHOPEDIC SURGERY, 



by cutting off the lower end of the upright at a distance of three inches 
from its normal length. This part is then forged flat on its outer sur- 
face for a distance of three and a half inches, and is rounded on its inner 
and threaded for screws by holes one-half of an inch apart. 

The part of the upright carrying the foot-piece is flattened at its 
upper two-thirds and lies on the outside of the lower part of the up- 
right. 

The end of the lower piece is drawn out to form two clips curving 
inward, which embrace between them the lower end of the upright, 
three and one-half inches above 
where it is cut off. Holes are drilled 
in both uprights and threaded for 




Fig. 560.— Convalescent Hip Splint. 
(See Figs. 128 and 129.) 



Fig. 561.— Modified Hip Splint. 
Fig. 123.) 



(Dane.) (See 



screws one-quarter of an inch in diameter. By means of screws pass- 
ing through these holes, the extension piece may be fastened to the 
upright at any desired level. 

In the case of adults and older children, it is desirable that the con- 
valescent splint should be jointed at the knee. This joint should be 
situated opposite the inner condyle of the femur. Of the various forms 
of joint in use those shown in the diagrams will be most serviceable. 
The illustrations will show their construction. 



PRACTICAL DETAILS OF APPARATUS. 625 

12. THE DOUBLE UPRIGHT HIP SPLINT. 1 

The special object of this form of hip splint is to furnish a firmer 
grasp upon the pelvis, and, when converted to the convalescent type, 
to transfer the support in walking to a point nearer the median line of 
the body. Its lower portion is similar to the Thomas knee splint, with 
the exception that the outer upright is made somewhat heavier and is 
prolonged above the ring for about one inch. The lower ends of the 
uprights are also furnished with some device for making traction, either 
in the form of a windlass or simply a pair of buckles. The pelvic por- 
tion of the splint is similar to that of the long traction hip splint, w r ith 
the addition of a second posterior pelvic arm. The lower pelvic arm is 
carried as far down as possible over the sacrum ; the upper follows 
closely under the curve made by the crests of the ilia. Each of these 
arms is prolonged around the opposite or sound side of the pelvis by 
means of a strip of No. 20 gauge steel, one-sixteenth of an inch thick, 
riveted to its free extremity. To these in turn are riveted the outer 
ends of the webbing straps, which complete the circuit by passing 
through two buckles, one at the extremity, the second three inches far- 
ther along on the single rigid anterior arm. The padding consists of a 
thick piece of leather, a little wider than the pelvic arms, riveted firmly 
on the inside to them and their flexible extensions. This leather is 
free only as a flap under the space occupied by the straps and buckles. 
The single perineal strap, w T hich passes through the groin on the sound 
side, is made of "window-chain " padded with felt, riveted to the lower 
pelvic arm behind and hooking over a bent staple riveted near the outer 
extremity of the anterior arm. 

13. THOMAS HIP SPLINT. 

The Thomas hip splint consists of: (a) an upright; (b) a chest 
band; (c) a thigh band; and (d) a calf band. 

{a) The upright runs vertically at one side of the patient's back and 
follows the line of the diseased leg. It reaches from the lower angle of 
the scapula to the junction of the middle and lower third of the leg, 
passing posteriorly to the hip-joint. It is bent in two places — one op- 
posite the fold of the buttock, and the other just above the hip-joint, 
so that the leg portion and body portion follow parallel lines, distant 
from each other from one-half to two inches, the leg-piece lying in a 
plane somewhat anterior to the body-piece. The bends should be 
round rather than angular. From the fold of the buttock to the lower 
end of the spine the leg portion is perfectly straight, as is also the upper 
portion of the splint from the bend opposite the joint to its upper end. 

^ohn Dane: Trans. Am. Orth. Assn., x. , 233; xiv., 74. 
40 



626 



ORTHOPEDIC SURGERY. 



The upright is usually twisted somewhat in its longitudinal axis, so that 
the body portion lies slightly to the side and flat against the curved out- 
line of the chest, while the leg portion lies directly posterior to the 
middle line of the leg. The buttock bend lies between the gieat tro- 
chanter and the tuberosity of the ischium. The upright for a child of 
ten should measure three-quarters to three-sixteenths of an inch, and 
is made of the softest and toughest iron available. Annealed steel is 
not the material to use. 

(b) The chest-piece is made of flat bar iron, which varies in width 
and thickness in proportion to the patient. It should be long enough 

to encircle the chest, leaving a gap be- 
tween its ends of one or two inches. It 
is joined to the uprights at a distance of 
one or two inches to the side of its middle 
point, the shorter wing encircling the chest 
on the side of the disease. The relative 
length of the two wings of 
the chest-piece may be de- 
termined by measuring from 
the lower angle of the scapula 
on the diseased side round 
each side of the chest to the 
point in front where it is in- 
tended that the piece should 
terminate. The upper end 
of the main upright is forged 
flat and bent over the chest- 
piece, and the two are made 
fast by a single rivet. In 
each end of the chest-piece, 
which is flattened for the 
purpose, a hole, three-quar- 
ters of an inch in diameter, is 
drilled for the fastening of 
the shoulder bandage. The 
chest-piece and the upright 
form a right angle with each 
other. 

(V) The thigh band is 
made of flat bar iron of about 
the same size as the upright, and is fastened to the inner surface of 
the upright by one rivet, at a point about one inch below the lower 
bend of the upright. The thigh band should be riveted to the upright 
so that its inner portion is one inch or more longer than the outer. 





Fig. 562. 



Fig. 563. 



FIG. 562.— Thomas Hip Splint Covered and Provided 

with Straps. 

FIG. 563.— Diagrammatic Outline. Parallelism of body 

and leg portions. (Ridlon.) 



PRACTICAL DETAILS OF APPARATUS. 



627 



(d) The calf band is made of flat bar iron, and is joined to the 
lower end of the upright by a single rivet in the same manner and in 
the same relative position as the thigh band. The inner surface of the 
splint next to the patient is covered with harness-makers' felt or ordi- 
nary boiler felting, about one-quarter of an inch in thickness. The 
whole is then covered with basil leather, a variety 
of sheep-skin, which is put on wet and snugly stitched 
into place. This shrinks when it dries, which will 
prevent any slipping of the cover of the splint. 

The final adjustment of the 
splint is made by means of 
wrenches until the bands fit 
closely to the leg and chest. 
Another piece of bandage is 
wound around the splint and 
leg at its lower extremity, and 
pinned securely to an anterior 
piece wound around the thigh 
above the knee. Shoulder- 
straps pass from the top of the 
upright over the shoulders to 
the anterior ends of the splint. 1 





Pig. 564. Fig. 565. 

Fig. 564.— Thomas Hip Splint, Double. (Ridlon.) 
Fig. 565.— Thomas Knee Splint with Ring Covered 

and Posterior Leather Attached. 



14. THOMAS KNEE SPLINT. 

The Thomas knee splint 
consists of: (a) a. perineal ring; 
(/?) two uprights ; and (c) a bot- 
tom plate. 

(a) The ring is made of 
round steel wire, one-quarter of 
an inch in diameter for a child 

of ten years, increasing to one-half of an inch for use in adults. The 
ring is an irregular ovoid, flattened in front and turned out at the 
posterior and inner portion of the thigh. It slopes from without in- 
ward and from before backward. It is fastened to the inner upright 
at an angle of one hundred and thirty-five degrees, and in the anterior 
plane the ring forms with the inner bar an angle of about one hundred 
and forty-five degrees. In making the ring the ends should be joined 
by welding in preference to brazing. The anterior surface of the ring 
is made flat on account of the flatness of the groin, its posterior part is 
expanded to accommodate the thickness of the buttock, and the antero- 
posterior tilt is to enable the patient to rest comfortably on the ring 

1 Ridlon and Jones : " Chronic Joint Disease." p. 106. 1894. 



628 ORTHOPEDIC SURGERY. 

with the tuberosity of the ischium. The measurement of the ring is 
the oblique circumference of the thigh taken as high up as possible at 
an angle of about one hundred and thirty-five degrees to the long axis 
of the leg. To this measure an inch is added to allow for the padding. 
(b) The uprights are made of five-sixteenth steel wire. The inner 
bar is welded to the upright at the angle mentioned. The other rod is 
fastened to the ring slightly farther back than the outer rod. The bot- 
tom of the rod should come two inches below the sole of the bare foot. 





FlG. 566.— Side View of Ring- of Thomas Knee Splint Uncovered and Covered, Showing 
Proper Shape. (Drawn from Ridlon and Jones.) 

As originally made by Mr. Thomas, the splint simply terminated in a 
loop where the inside upright was bent round below the foot to return 
as the outside upright. 

(c) The Bottom Plate. — For use in walking, however, some form of 
foot plate is necessary. For the more acute cases it is convenient to 
weld to the bottom of the uprights a base plate or patten, oval or round 
in shape, three inches in diameter, with a hole one and one-half inches 
in diameter in its centre. This is made of an ordinary iron washer, 
one-quarter of an inch in thickness. It should be perforated by two or 
more holes, in order that a piece of leather may be riveted to the under 
side for walking. 1 

Measurement. — The length of the inner upright is the distance from 
the tuberosity of the ischium to the sole of the foot plus two or more 

1 At the Hospital for the Ruptured and Crippled in New York there is in use 
an arrangement for protecting the bottom of the splint in which the uprights termi- 
nate below in a cross bar, which is put through a section of rubber carriage tire, 
forming an efficient and inexpensive foot-piece. 



PRACTICAL DETAILS OF APPARATUS. 



629 



inches. The required width at the knee and ankle should be given in 
order that the bars may clear the side of the limb. 

Padding. — The ring is padded with boiler felting for a thickness of 
about one-half of an inch on its outer portion and from one to one and 
one-half inches in thickness on its inner posterior portion. This is 
then covered with basil leather or a tanned sheep-skin put on wet and 
sewed after the manner of the harness-maker along the lower and outer 
border of the ring, where the seam will not chafe the patient. 1 Two 
strips of basil leather, about three 
inches in width, are sewed at one 
end round one of the side bars, 
the other end being left free and 
of sufficient length to be drawn 
across to the opposite bar, and 
when sewed there to form a sup- 
port for the back of the limb 
when the splint is applied. One 
of these straps is to be placed at 
the back of the knee, or above it 
if the knee is too sensitive, and 
the other at the back of the 
ankle. When the splint is ap- 
plied the leg is fastened to it by 
means of a roller bandage carried 
to and fro around the upright 
and fastening in front of the leg just above the knee, where it passes 
over a thick pad of metal or of leather placed in front of the lower end 
of the thigh. A roll of bandage is also fastened in the same manner 
over an anterior pad placed in front just below the knee. 





Fig. 567.— View of Front and Back of Ring of 
Thomas Knee Splint Covered, Showing De- 
pression at Back for Tuberosity of Ischium. 
(Drawn from Ridlonand Jones.) 



15. THOMAS CALIPER SPLINT. 

In cases which are not sufficiently acute to require the use of the 
plate attached below the foot, the lower ends of the inner and upper 
bars may be turned sharply inward at a right angle at a point one inch 
below the bottom of the heel of the boot. 2 The measurement for this 
may be taken by applying the unfinished splint in its proper relation 
and marking on the upright the place where the bend should occur, or 
the distance may be measured from the tuberosity of the ischium to a 
point one inch below the bottom of the sole of the boot. The splint is 
then fastened to the boot by means of a hole drilled through the heel 
from side to side, into which a steel tube is inserted, of a proper calibre 

1 Ridlon and Jones: " Chronic Joint Disease," Chicago, 1894. 

2 See Fig. 577 for detail of foot-piece. 



630 ORTHOPEDIC SURGERY. 

to accommodate the ends of the splint. The bends in the ends of the 
splint, which should each be three-quarters of an inch long, are passed 
into this tube and are held together by the leather straps above men- 
tioned. In the use of this splint a triangular piece should be cut away 
from the back of the shoe and a loose piece of leather sewed on over it. 
This triangle, with its apex upward, should begin well above the coun- 
ter of the shoe, and at its base should be as wide as the width of the 
heel. In this way excoriation of the heel can be avoided. The splint 
may be finished by being blued or japanned. 

16. JOINTED KNEE SPLINT. 

This apparatus consists of (a) two uprights; (&) an arm for perineal 
band; (c) a foot-piece; and (a?) two posterior bands for the thigh and 
one for the calf. 

It is intended to serve as an apparatus for fixing the knee at any 
angle and for making traction upon it if desired. It also furnishes pro- 
tection from weight-bearing in walking. 

(a) Uprights. — The outside upright reaches from the level of the 
trochanter at the top to two and one-half inches below the sole of the 
bare foot below. It is constructed of flat machine steel, five-eighths of 
an inch thick. The outside is constructed in two parts, which are 
joined together opposite the inner condyle of the femur to make a 
joint. This joint may be left movable or may be fastened at any angle. 
The two ends of the upright which form this joint are flattened into 
discs, the centre of which is drilled for a hole for the formation of the 
joint. The two discs where they come in contact are ground flat, and a 
disc of flat steel, two inches in diameter, is placed over the inner sur- 
face of the joint. Through a hole drilled in its centre a rivet is passed 
binding the three pieces together, forming an antero-posterior joint. 
This joint should lie somewhat back of the plane of the uprights, and 
for this purpose the ends of the uprights which are to form the joint 
are bent back on the flat about one and one-half inches. This joint is 
set at any desired angle by means of a set screw passing through the 
upper end of the lower half of the upright, passing into holes drilled in 
the steel disc one-half of an inch apart. This plate should be oblong 
in shape, about two inches wide and three or four inches in length. 

The inner upright runs on the inside of the leg from a point one or 
two inches below the perineum to the bottom piece. It is lighter than 
the outside upright, and the two pieces of the upper and lower parts are 
joined together opposite the inner condyle of the femur by a simple 
antero-posterior joint. 

(b) The arm for the perineal bands consists of an anterior portion, 
a vertical portion, and a horizontal posterior portion curved to fit the 



PRACTICAL DETAILS OF APPARATUS. 



6 3 I 




1 r 




LJ 



pelvis. The anterior arm reaches from the top of the upright, curving 
forward and slightly downward to a point just inside the origin of the 
adductor tendons. The vertical portion of the perineal arm rises in the 
line of the upright to just below the level of the posterior superior spine 
of the ilium. It then turns at a right angle back- 
ward, and runs, following the curve of the pelvis, 
to a point just below the posterior superior spine of 
the ilium. This arm is drilled at its front and back 
ends with holes, to which are fastened buckles to 
carry the perineal band. The perineal arm should 
be made of cast steel, live-eighths of an inch wide 
and one-quarter of an inch thick. The horizontal 
part of the perineal arm is curved to fit the outside 
of the upright where it crosses it and is riveted to 
it. A steel pad, shaped to fit the 
contour of the hip, is placed inside 
of the upper end of the outside up- 
right. This plate should be oblong 
in shape, about two inches wide and 
three or four inches in length. 

(c) The Foot-Piece. — The foot- 
piece of the splint, which connects 
with the outside and inside uprights 
or as a continuation of them, is fur- 
nished with the windlass traction ap- 
paratus described in speaking of the 
traction hip splint. This should 
come at a point one and one-half 
inches below the shank of the boot. 

(d) The posterior bauds are two 
in number, both semicircular in shape 
and convex backward to follow the 
contour of the leg and thigh. The 
arm passing back of the thigh is 
broadened at its upper end, and 
where it joins the outer upright is 
from one to two inches higher than 
where it joins the inner upright. It 
is fastened by rivets to the top of 
both uprights, and its upper edge should follow the line of the gluteal 
fold and should be well below it. This thigh-piece should be two inches 
wide at its inner end and three inches wide at its outer end, and should 
be made of No. 15 gauge sheet steel. The posterior calf band should 
encircle the calf at its upper third, being curved to fit it, and fastened 



~4 




Fig. 



Fig. 569. 

for Adjustin 



the 
Splint. 



FIG. 568. — Application 

Length of the Thomas Knee 

(Burrell.) 
Fig. 569. — Splint for Traction on Knee at 

anv Angle. 



632 ORTHOPEDIC SURGERY. 

to the inside of both uprights at the proper point. It should be one 
inch in width. 

Buckles should be fastened by rivets to the upper end of the inner 
upright and at a corresponding point on the outer upright to make 
upward traction if desired. Lacings of stout sole leather are fastened 
to the upright, lacing in front to encircle and steady the thigh and 
calf. They are furnished with studs for lacing, half an inch apart. 

When the disease has become convalescent a movable joint, which 
can be stopped at any angle by a pin in the disc, may be substituted for 
the fixed joint, so that the patient can bend the knee in sitting. This 
type of joint has been described in speaking of the convalescent hip 
splint. At this stage also the traction arrangement of the foot-piece 
may be removed and the splint used as a protection splint, which can 
be bent at the knee when desired. In this case it is fastened to the 
boot in a manner similar to that described for the convalescent hip 
splint. 

17. FIXATION ANKLE SPLINT. 

In cases convalescent from ankle-joint disease, in which it is desired 
to prevent motion but which are sufficiently recovered to bear weight, 
a simple fixation splint may be substituted for the plaster-of-Paris band- 
age. This consists of (a) two uprights; (b) afoot-piece; and (V) a 
posterior calf band. 

{a) The uprights run on the inside and on the outside of the leg 
from the bottom of the foot-piece to a point one inch below the tubercle 
of the tibia. They should be curved to fit the outline of the leg, but 
should be bent out so as not to touch the malleoli. They should be 
made of No. 10 gauge machine steel, one-half of an inch wide. One 
continuous piece of steel may be used, passing down the leg as the 
outside upright, being bent at a right angle to pass under the foot-piece 
and being turned up opposite the inner border of the foot-piece, to re- 
turn up the leg as the inside upright. 

(b) The foot-piece consists of a plate of cast steel, one-quarter of an 
inch thick, forged to the shape of the sole of the foot, extending in 
front to just behind the cleft between the toes and the foot. On the 
side it should be one-quarter of an inch narrower on each side than the 
whole width of the foot, and it should stop one-half of an inch in front 
of the back part of the os calcis. It should be curved to fit approxi- 
mately the sole of the foot, and its inner surface should be slightly 
higher than the outer surface. It should be riveted to the piece of 
steel connecting the two uprights, passing across on its under surface 
at a point below the malleoli. 

(e) T\\<t posterior calf band joins the two upper ends of the upright, 
and is curved backward to fit the posterior surface of the calf. It con- 



PRACTICAL DETAILS OF APPARATUS. 633 

sists of a piece of steel, one and one-eighth inches wide and No. 15 
gauge, and is riveted to the upper inner surface of the two uprights. 
This band is padded with felt and covered with leather. A cuff of 
stout leather is riveted to the upright, following the contour of the calf 
and lacing in front. A piece of softer leather, cut like the upper of a 
low shoe, ending in front behind the metatarso-phalangeal joint of the 
great toe and with the part over the point of the heel cut away, is riv- 
eted by its under surface to the sole plate, to pass over the top of the 
foot, and laces down the middle line. It should be protected by a fly 
covering the junction of the two pieces, sewed to the inner side of one 
of them, and the edges of the leather pieces coming over the dorsum 
of the foot should be perforated for eyelets one-half of an inch apart. 
The posterior part of this foot lacing should be split in the vertical line 
behind and shortened sufficiently to set snugly back of the heel. 

18. KNOCK-KNEE BRACE. 

Measurements for knock-knee braces are given for a child of about 
the age of three. 

Knock-knee braces consist of three parts : (a) an upright ; (J?) a 
foot-piece ; and (e) two posterior bands. 

(a) The upright is made of cast steel, five-eighths of an inch wide 
and one-eighth of an inch thick, and runs along the outer side of the 
leg from a point opposite the ankle-joint to a point one-half of an inch 
above the trochanter. The top of the upright from this point curves 
backward to a point just below the posterior superior spine of the ilium, 
following the contour of the buttock. The angle of the curve at the 
top of the upright is, of course, determined by the relative position of 
the two points given. The bottom part of the upright is flattened and 
enlarged, and its centre bored with a hole, one-quarter of an inch in 
diameter, through which is to pass the spindle of the ankle-joint. 

(J?) The foot-piece consists of a triangular piece of steel, nearly as 
wide as the boot at its back, and at the apex which comes in front it 
terminates in a rounded point. It should be approximately one and one- 
half inches long, and should be made of machine steel, one-quarter of an 
inch thick. It is fastened to the inside of the bottom of the boot by 
rivets, and from its inner border just below the upper malleolus there 
runs up from it a vertical arm of about the same size and width as the 
upright, to join the upright opposite the ankle-joint. It is curved so as 
to clear the outer border of the foot, and is joined to the bottom of the 
outside upright opposite the malleolus as a free joint moving in the 
antero-posterior plane. The inner surface of this joint lying next to 
the malleolus should be furnished w r ith a circular pad of steel, about 
the size of a twenty-five-cent piece, padded with felt and covered with 



^34 



ORTHOPEDIC SURGERY. 



leather to protect the outer malleolus from pressure. The top of the 
upright, where it bears on the side of the thigh, is furnished with a 
small pad. 

(c) There should be riveted to the inner side of the upright two 
semicircular posterior bands, curved posteriorly, made of sheet steel, 
two inches wide, No. 17 gauge, which should cross the lower third of 
the thigh and the upper third of the calf. These points are connected 
by a strip of steel running from the middle of the upper one to the 

middle of the lower one in a vertical line. 
This steel should be one-half of an inch 
wide and one-eighth of an inch thick, and 
should be fastened to the posterior sur- 
faces of the thigh and calf bands. 

There should be a buckle at the pos- 
terior end of the curved portion of the 
upright and another buckle on each side 
where the upright begins to bend upward 
and backward. The posterior buckles 
should be connected by a strap running 
behind the body, and the anterior buckles 
by a strap running in front. By tighten- 
ing or loosening these straps, in connec- 
tion with the curve of the posterior arms, 
any degree of inversion or eversion of the 
foot may be secured in walking. Bend- 
ing the band outward and loosening the 
posterior strap secures eversion, and 
bending the bands inward and tightening 
the anterior strap secures inversion. 
The tops of the uprights where they lie 
in contact with the patient should be 
padded with felt covered with soft leather. 
The knee is pulled outward to the upright by a square or oblong pad of 
leather lined with sheepskin. This pad should cover the inner surface 
of the knee, and should be about four inches long by three inches wide. 
To the upper and lower corner and to the middle on each side are sewed 
leather straps running sideways, the anterior ones passing in front of 
the leg and the posterior behind the leg, to fasten into leather buckles, 
one-half of an inch wide, riveted by leather tags to three buckles on the 
outside of the upright — one at a point opposite the knee, and one at 
a point two inches above, and one two inches below the knee. There 
are two buckles at each level, one facing forward and the other back- 
ward. The splint is finished by being blued or japanned. 

Instead of finishing the top of the upright by bending it backward, 




Fig. 570.— Knock-knee Brace. 



PRACTICAL DETAILS OF APPARATUS. 635 

it may be finished by being joined to a curved band lying transversely 
along the side of the pelvis. The upright is made as if it were to be 
curved upward and backward and carried to the height where the bend 
begins. It is then flattened and its centre drilled for the formation of 
a joint. A band to lie against the side of the pelvis, one inch above the 
level of the trochanter, is then made of sheet steel, one inch wide, No. 
14 gauge, and in length reaching from just behind the anterior superior 
spine to the posterior superior spine of the ilium. This band is curved 
to fit the pelvic outline, and is padded with felt and covered with 
leather. At a point vertically over the trochanter is riveted to its out- 
side a piece of steel of the same material, flattened at its lower end to 
make with the top of the upright an antero-posterior joint opposite the 
trochanter. The front and back ends of this pelvic band are furnished 
with buckles to carry anterior and posterior straps. The apparatus is 
slightly less unsightly and a little more comfortable in older children 
than is the kind first described. The measurements are sufficiently 
well defined in the description of the apparatus, the length of the up- 
right being the distance from the lower part of the sole of the boot to 
a point on a level with the trochanter. 

19. BOW-LEG IRONS. 

Measurements for bow-leg irons are given for a child of about the 
age of three. They are similar in construction to the knock-knee 
braces just described, and certain details of construction need not be 
repeated. The apparatus consists of two parts : (a) an upright and (b) 
a foot-piece. 

(a) The upright runs in the middle of the inner surface of the leg 
from a point opposite the inner malleolus to a point an inch or more 
below the origin of the adductor muscles. At this point the upright 
curves round the front of the thigh in a line upward and outward 
to a point just posterior to the trochanter. This anterior arm is 
convex forward, to fit the curve of the upper part of the thigh. The 
upright and anterior arm are made of one-half-inch cast steel, one-six- 
teenth of an inch thick. It is jointed below, opposite the internal mal- 
leolus, to a foot-piece similar to that described in knock-knee, except 
that the arm from the foot-piece to the ankle-joint runs on the inner 
side of the foot. The inner surface of this joint should be protected by 
a pad similar to that described in the knock-knee apparatus. The up- 
per end of the upright is padded with felt and covered with leather to 
prevent chafing where it touches the skin ; and buckles, two on each 
upright, one facing forward and one back, are fastened on the top of 
each upright. From these leather or webbing straps run, one in front 
of the patient and one behind the patient, to the opposite side. In the 
case of a single bow-leg upright these' straps run to a pad of leather on 



6^6 



ORTHOPEDIC SURGERY, 



the opposite trochanter, which serves as a point of resistance for cor- 
rective pressure on the leg. In the apparatus for double bow-legs the 
upright at the opposite side serves to furnish resistance instead of the 
pad. In double bow-leg, therefore, one strap connects the uprights in 
front and the other behind the body. By the curve of the arms and by 
tightening of the anterior or posterior strap the feet and legs may be 
inverted or everted, as in the knock-knee braces. 

(b) The foot-piece is in construction similar to that described in 
knock-knee. 

Pressure upon the curve is made by an oblong piece of leather, sim- 
ilar to that described in knock-knee, furnished with two or three straps 





Fig. 571.— Bow-leg Irons. 



FlG. 572. — Antero-Posterior Bow-leg Brace. 



at its front and back border, to pass in front of and behind the leg, and 
fastening into buckles upon the upright at appropriate points. This 
pad should embrace the entire curve of the leg. 

The measurement for bow-leg irons is sufficiently described in 
speaking of the uprights. The length is along the inner side of the 
leg from the bottom or sole of the shoe to a point one inch or more be- 
low the origin of the adductor muscles. The distance is then measured 
from this point upward and backward to a point slightly posterior to 
the trochanter. The ankle-joint comes at a point opposite the inner 
malleolus. 



PRACTICAL DETAILS OF APPARATUS. 637 

When the curve involves only the lower tibia, the inner upright 
need not be carried above the inner condyle of the femur, where it ends 
in a circular steel pad fastened to its inside to press on the inner con- 
dyle of the femur, which is finished like those described in the appara- 
tus for bow-legs and knock-knee, In this case a semicircular band is 
added to the apparatus just below the upper end, fastening around the 
leg. 

20. ANTERIOR BOW-LEGS. 

In addition to the apparatus described, in bow-legs with an anterior 
curve of the tibia two additional parts are needed. These consist of 
posterior semicircular strips of steel, curved to the outline of the leg, 
one fastened to the upright just below the knee, and the other just 
above the heel. These are connected at their outer ends by a strip of 
steel running from the outer end of one to the outer end of the other. 
These furnish points for the attachment of buckles, into which straps 
are buckled passing from an anterior leather pressure pad. In this 
way backward pull is exerted upon the curved portion of the leg. 

21. ANTERO-POSTERIOR BOW-LEG BRACE. 1 

The object of this splint is to prevent as far as possible flexion at 
the knee, while pressure is exerted upon the outward bowing of the leg. 
It consists of : (a) two uprights ; (J?) a thigh band ; (c) an ankle band ; 
(d) a foot-piece. 

(a) The Uprights. — These consist of pieces of sheet steel, No. 16 
gauge, five-eighths of an inch wide. The anterior runs from a point 
one-quarter of an inch above the level of the ankle up the median line 
of the leg to a point a little below the level of the gluteal fold. It 
may be bent slightly outward at the knee if necessary. The posterior 
upright starts three-eighths of an inch lower than the anterior, and 
runs up the median line of the leg behind to the level of the top of the 
anterior upright. 

(b) The TJiigh Band. — This is a flat strip of No. 16 gauge sheet 
steel, seven-eighths of an inch wide, bent to fit the curve of the thigh 
on its inner side, and riveted to the top of each upright. 

(e) The ankle band is a similar strip of steel connecting the lower 
ends of the uprights. It is cut somewhat curved, with the convexity 
downward, that its middle and lowest point may come opposite the cen- 
tre of the internal malleolus. Both bands are padded on their inner 
surface with felt and covered with leather. 

id) The foot-piece, made of machine steel forged to fit foot, begins 
as a round rivet joint, so as to allow motion in flexion and extension, 

1 John Dane : Trans. Am. Orth. Assn., vol. xi., p. 151. 



6 3 8 



ORTHOPEDIC SURGERY. 



situated in the centre of the ankle band ; it extends downward to the 
level of the sole of the shoe, where it is bent inward at a right angle 
beneath the sole and expanded into a flat plate, which is riveted to the 
sole. The heel of the shoe is then replaced, covering the posterior por- 
tion of this plate. . 

Two flaps of leather are riveted one upon each of the uprights, 
beginning at the bottom, and reaching to just below the knee, or 
three-quarters up the thigh, according to the location of the bowing. 
These are of such a width that they overlap each other slightly 
around the outer side of the leg, and are finished with a row of holes 
or eyelets for lacing them together. A strap and buckle are riveted 
to the extremities of the thigh band, to pass round the outer side of 
the leg. 

22. TEMPERED STEEL UPRIGHTS. 

This form of apparatus consists of (a) a horizontal pelvic band, (&) 
two uprights, and (c) a cross-bar. 

(a) The horizontal pelvic band encircles the posterior part of the 
pelvis from a point one inch posterior to the anterior superior spine 

on one side to a similar point on 
the other side. It is curved to- 
fit the contour of the pelvis and 
should lie close against it. It is 
made of No. 15 gauge sheet steel, 
one and one-eighth inches wide. 
The uprights run from the pos- 
terior pelvic band along the sides 
of the spine to a point about on 
a level with the acromion process. 
At this point they are curved 
outward on the flat by an angular 
turn at an angle of about forty- 
five degrees, and run upward and 
outward to a point just behind 
the anterior border of the trape- 
zius. In their upper part they 
are curved to fit the contour of 
the shoulders and should lie flat 
against the skin. 

(b) The uprights at their 
lower part are farther from each other than they are at the top. At 
the bottom their outer edges should be separated by a distance some- 
what less than the distance between the two posterior superior spines. 
At the top they should lie over the transverse processes. They are 




FIG. 573— Tempered Steel Uprights. 



PRACTICAL DETAILS OF APPARATUS. 639 

made of No. 16 gauge sheet steel, five-eighths of an inch wide, and 
should follow the outline of the back in general, but whatever correc- 
tion is desired in the standing position is to be made by bending the 
uprights to fit the curve of the back in a corrected position rather 
than the curve of the back in the faulty position. 

(c) The cross-bar consists of a piece of steel, which in length should 
be one inch less on each side than the breadth of the body at the level 
where it is placed. It is riveted transversely to the uprights at a point 
just below the posterior fold of the axilla. The projecting ends beyond 
the bars should not rest on the scapulae, but if necessary should be set 
backward by an angular curve to clear the scapulae. These are made 
of the same material as the uprights. 

Buckles. — Holes are drilled for buckles at each anterior end of the 
pelvic band, at the top of the uprights, and at the ends of the cross-bar. 
Buckles are placed on the ends of the pelvic band, and the cross-bar 
and axillary straps are riveted to the upper ends of the uprights, one on 
each side. The brace is finished by being covered with leather sewed 
down the back throughout, or by being nickel-plated and having its an- 
terior surface only covered with padded leather strips slightly wider 
than the metal parts of the brace. These are attached to the brace by 
loops running around the uprights, pelvic band, and the cross-bar. 
The brace is attached to the body at the top by means of axillary 
straps similar to those described in speaking of the antero-posterior 
support, and by means of a broad belt of sheep-skin or surcingle cloth, 
to each end of which webbing or leather straps are sewed, which con- 
nect the anterior ends of the pelvic band by passing around the lower 
part of the bottom. In cases in which there is much prominence of 
the abdomen, it is desirable to add an abdominal band, from four to six 
inches wide, running from one upright around the bottom to the other 
upright. 

23. BRACE WITH MOVABLE SHOULDER-PIECES. 

This brace is really the tempered steel brace already described, with 
a special cross-bar and shoulder-pieces at the top. It consists of: (a) 
a waist band; (b) two uprights; (c) a cross-piece, bearing at each end a 
movable L-shaped shoulder-piece. 

(a) The waist band is to be made and finished as described for the 
tempered steel brace. 

(b) The nprigJits likewise, except that they should end straight at 
the level of the first dorsal spine, and that they should be one inch 
apart throughout. 

(c) The cross-piece — a plate of sheet steel, four to four and one-half 
inches long, one inch wide, and one-sixteenth of an inch thick — is riv- 



640 



ORTHOPEDIC SURGERY. 



eted with its front face to the top of the uprights by four iron rivets. 
One-quarter of an inch from each outer edge is a rivet hole for attach- 
ment of the shoulder-piece, which is riveted loose, so as to allow the 
shoulder-piece to move freely in one plane ; the L-piece is fastened to 
the front face of this cross-plate, one-half of an inch from the rounded 
inner edge of the L-piece. The L-piece is made, of the same material, 
one-sixteenth of an inch thick, of a uniform width of one-half of an 
inch. The attached arm should extend horizontally to a point on the 




Fig. 574.— Back Brace with Movable Shoulder- 
pieces. (A. Thorndike.) 



Fig. 575.— Front View of Straps and Apron in 
Back Brace with Movable Shoulder-pieces. 



shoulder vertically above the posterior axillary fold when the arm is at 
the side, from which point the other arm descends at right angles 
three inches. A pattern of stiff paper should be made. A webbing 
strap, four inches long, bearing a buckle one inch from the free end, is 
riveted to the angle, and another eight inches long to the tip of the un- 
attached arm of the L-piece. The webbing should be about five-eighths 
of an inch wide and needs no padding ; for, as the shoulder-pieces and 
straps follow the movements of the arm, they do not rub. A piece of 
thick leather covers the front of the upper third of the uprights and the 
cross-piece, to prevent the inward movement of the posterior border of 
the shoulder-blades pinching the skin against the uprights. The finish 
should correspond to the rest of the brace. 



PRACTICAL DETAILS OF APPARATUS. 



641 



24. TORTICOLLIS BRACE. 

The brace for the retention of the head in the overcorrected posi- 
tion after operation for torticollis is a modification of the brace already 
described as the anterior head support. It consists of (a) a chest- and 
shoulder-piece which serves as a base for the rest of the apparatus, (b) 
a wire chin-piece, and (c) an occipital piece of steel. 

(a) The chest- and shaulder-piece is not made of wire, as in the ante- 
rior support, but of flat cast steel, one-half of an inch wide, No. 8 gauge. 
In front it is curved in the shape of a 
U, and its bottom part is as wide as 
the horizontal distance between the 
middle of the clavicles running at the 
level of the xiphoid cartilage. From 
this level it is curved on the flat to 
run up the front of the chest vertically 
on each side. It is bent to rest on 
the shoulders, not bearing on the 
clavicle, and each side of the upright 
is then continued down the back to 
about the level of the tenth rib, being 
curved to fit the back. It is padded 
with felt and covered with leather 
stitched on the side away from the skin. 
Its lower posterior ends are to be pro- 
vided with one buckle, into which is 
fastened a strap going around the 
chest. At a point just below the pos- 
terior fold of the axillae are fastened 
two other buckles on the upright, from 
which pass straps along the sides of 
the chest below the axilla into buckles 
attached to the vertical part of the U -piece at an appropriate level. 

{b) The chin-piece is identical in construction with that described in 
the anterior head support, except that the hard-rubber or celluloid pad 
for the chin is set to one side of the middle line of the ring, and the 
side of the chin-piece with which it is desired to make pressure upon 
the chin to twist the head is carried up into a flange following the con- 
tour of the jaw, to a point half-way from the tip of the chin to the angle 
of the jaw. This chin-piece is put in any position which serves to hold 
the head with the required amount of twist. 

(r) The occipital piece is made of a strip of machine steel, one- 
eighth of an inch thick and three-eighths of an inch wide, running 
horizontally behind the head and bent around the wire upright on one 
4i 




Fig. 576.— Torticollis Brace. 



642 



ORTHOPEDIC SURGERY. 



side, forming a hinge, and secured to the opposite upright by a hook 
catch made by bending over its end. From one side of this upright 
there runs up a steel stem of wire, three-eighths of an inch in diameter, 
flattened at its lower end and riveted to the occipital piece. This 
should rise to the level of the parietal eminence of the head. Riveted 
to this at its top, which should be flattened, is a pad of steel or phos- 
phor bronze, oval in shape, approximately two inches in height by three 

inches in breadth, which is shaped to fit 
the contour of the head and tips the 
head to the desired side. This pad is 
padded by felt and covered with leather. 

25. CALIPER APPARATUS FOR 
ANTERIOR POLIOMYELITIS. 

A modification of the Thomas cal- 
iper splint is the simplest apparatus for 
cases of paralysis of the leg, in which 
the power of the extensor muscles of 
the thigh is not sufficient to hold the leg 
straight in standing or walking. It is 
also to be used in cases of spastic par- 
alysis in which it is desired to hold the 
knee extended. The apparatus consists 
of {a) two uprights and (b) a posterior 
thigh band. 

(a) The Upright. — The inside of the 
upright runs from the bottom of the 
sole of the shoe to a point at least one 
inch below the perineum. The outer 
upright runs from the sole of the boot 
to a point at least one and one-half 
inches below the top of the great tro- 
chanter. A line connecting these two 
points should be at least one inch be- 
low the fold of the buttock. At the 
lower end of the uprights, where they 
are on a level with the bottom of the sole of the shoe, each upright is 
turned inward at a right angle for a distance of at least one inch, to 
fasten into a hole in the bottom of the heel of the shoe, as described 
in the Thomas caliper splint. The uprights may be curved to follow 
the inside and the outside of the leg, but are stronger if they are left 
straight. They are slightly less noticeable if they are curved to follow 
the outline of the leg. 

(I?) The posterior thigh band is made of a strip of sheet steel, one 




PIG. 577. — Caliper Apparatus for Ante 
rior Poliomyelitis. 



PRACTICAL DETAILS OF APPARATUS. 643 

and one-quarter inches wide and one-sixteenth of an inch thick, encir- 
cling the posterior half of the upper part of the thigh and shaped to fit 
it. It is soldered to the upper parts of the uprights and made straight 
across or slanting downward from without inward. It should be padded 
with felt and covered with leather. The knee is held in extension by 
an oblong piece of leather, four inches long and three and one-half 
inches wide, made of sole leather and faced with sheep-skin. In its cen- 
tre is cut a hole, the size of the patella, in order to avoid pressure on 
that bone. From the top and bottom on each side, stitched to the an- 
terior surface of the knee-cap, a strap six inches long and one-half of an 
inch wide runs sideways, passing around the upright and back to buckle 
at the knee-cap at the origin of the strap. To prevent the knee-cap 
from slipping clown, it is desirable to solder on the outside of the up- 
right, where the strap passes round it, a small wire loop, through which 
pass the two top straps. In cases in which very much pressure comes 
upon the knee-cap, it may be modified by anterior bands of leather run- 
ning from one upright to the other, at the lower third of the thigh and 
the upper third of the calf. These bands are made in the same way 
and of the same material as the knee-cap. 



25. SUPPORTING LEG BRACE FOR ANTERIOR POLIO- 
MYELITIS. 

In infantile paralysis involving the leg and foot, it is frequently nec- 
essary that a supporting brace to prevent flexion or hyperextension of 
the knee should extend up from the foot-piece. This may be jointed at 
the knee to enable the patient to sit down with greater comfort. This 
apparatus consists, in addition to the foot-piece, of {a) two uprights, (b) 
two or three posterior calf bands, and is used only in connection with 
one of the foot-pieces described in speaking of the various deformities 
of the foot caused by infantile paralysis, in connection with one of 
which it should always be used. Another form of the apparatus, 
shown in the figure, has only one upright. 

(a) The outside upright runs from the point opposite the outer mal- 
leolus to a point one and one-half inches or more below the trochanter. 
It should be made of flat machine steel, five-eighths of an inch wide, 
one-quarter of an inch thick, and should be curved to follow the outline 
of the leg, a space being left so that the upright will not touch the outer 
malleolus or the outer surface of the knee-joint. For the rest of its 
course it should be closely applied to the leg. The inner upright is 
made in the same way, running from the internal malleolus to a point 
one inch or more below the perineum. A line connecting the two up- 
rights, passing round the back of the thigh, should be oblique and lie 
at least one inch below the fold of the buttock. Both uprights should 



644 



ORTHOPEDIC SURGERY. 



be jointed at the knee by antero-posterior joints moving in the same 
plane, and the outer joint should be furnished with a drop or spring 
catch, to be loosened when the patient sits down. The upper thigh 
band should be three inches wide at its outer end and one and three- 
quarters inches wide at its inner end, and should form the posterior 
half of a circle, being shaped to fit the back of the thigh. It is riveted 
to the inside of the top of the uprights, and is made of sheet steel, No. 
15 gauge. 

{b) There should be posterior bands at the lower third of the thigh 
and the upper third of the calf, one inch wide and made of the same 






FIG. 578.— Supporting Leg Brace for Ante- 
rior Poliomyelitis, with One Upright. 



Fig. 579.— Mechanism for Locking Knee-joint. 
(H.L.Taylor.) 



steel, curved to fit the posterior surface of the thigh and calf, riveted 
to the uprights. Below the ankle-joint the apparatus is the same as 
that described in speaking of the various forms of talipes. The meas- 
urements of the apparatus have been indicated in describing the differ- 
ent parts of it. The apparatus may or may not require a knee-cap, 
and the thigh and leg are supported by cuffs of leather running from 
the top of the splint to just above the knee and from the tubercle of 
the tibia to a point two inches above the malleolus. These straps are 
split in the middle line in front, and fit the calf and thigh closely be- 



PRACTICAL DETAILS OF APPARATUS. 



645 



hind, and are laced by means of hooks or eyelets placed at one-half- 
inch intervals near the front border of the cuff. 

In case the foot-piece has only one upright, it is connected with the 

trvvAv 





o 



Fig. 580.— Self-locking Spring Catch. 



FlG. 581.— Drop Catch. 



leg part of the apparatus as follows : The upright running from the 
foot-piece, whether on the outside or inside, is made heavier than the 





G 



rJ 




FIG. 582.— Supporting Apparatus in Paralysis of Anterior Thigh Muscles. 



6 4 6 



ORTHOPEDIC SURGERY. 



other. At the lower third of the calf, the upright which is not con- 
nected with the foot-piece is turned backward at a right angle, being 
curved on the flat, and runs around the back of the calf, being curved 
with its convexity backward, and is riveted at its free end to the outer 
side of the long upright which connects with the foot-piece. It should 
run transversely across and should be closely applied to the back of the 
calf. Above this point the apparatus is the same as that described 
above, except that the upright connecting with the foot-piece must nec- 
essarily be somewhat heavier than the other. 

The apparatus thus consists of a foot-piece; an upright connecting 
with it either on the outside or the inside, running the whole length of 
the leg; and another upright running from the lower third of the calf 
the whole length of the leg, or one upright may be used passing be- 
hind the calf as described. Either form of apparatus is finished by 
being nickel-plated, blued, or japanned. 

The form of foot-piece required to complete the leg apparatus is 
determined by the kind of deformity existing in the foot. 



27. EQUINO-VARUS SPLINT. 

This apparatus consists of (a) a sole plate, (b) an upright, and (V) a 
calf band. 

'(a) The sole plate consists of a bottom part and side flanges. The 
sole plate is made of sheet steel, No. 16 gauge. The bottom part is 
shaped to fit the weight-bearing portion of the normal sole. The plate 
is cut so that flanges can be turned up to furnish press- 
/C^^n^ ure on the inner side of the end of the os calcis and 
VsJCL^ q pgf 1 1 J the head of the first metatarsal and its adjacent pha- 
lanx. The intervening space on the inner side of the 
plate is cut out to lighten the brace. 

Length. — The sole plate should extend from the 
posterior border of the heel to the heads of the meta- 
tarsals. The forward side flange should extend from 
the proximal end of the head of the first metatarsal to 
the joint between the phalanges of the great toe. The 
posterior side flange presses on the inner side of the 
os calcis, on the portion posterior to a line 
from the internal malleolus extending down- 
ward. The plate is in front as wide as the 
breadth of the ball of the foot, and behind 
as the width of the os calcis. The shape 
of the plate can be indicated by cutting it 
out of cardboard and fitting it to the foot. 

(b) The uprigJit extends up the side of the leg and consists of two 
parts, a lower and an upper, five-eighths of an inch wide and one-quar- 




FlG 



583. — Splint for Equino- 
varus. 



PRACTICAL DETAILS OF APPARATUS. 



647 



ter of an inch thick. The lower part is of steel plate, No. 8 gauge, 
forged at the bottom to fit the posterior part of the sole plate, to which 




Mg. 584. — Inner and Outer Views. 

it is fastened by three steel rivets. It is bent at right angles on the 
inner edge of the sole plate, and extends on the line of the internal 
malleolus as hi°:h as one-half of an inch above the malleolus. 





FIG. 585. — Club-foot Shoe, from Front and Back. Arrows show direction of force exerted by 

straps. 

The upper part is a flat steel bar, one-half to three-quarters of an 
inch wide and No. 10 gauge, and extends from just below the malleo- 
lus to the level of the insertion of the inner hamstring. 



648 



ORTHOPEDIC SURGERY. 



In order to prevent the dropping of the foot into the position of 
equinus, the joint opposite the inner malleolus is made as follows : The 
two parts of the upright which join at this place are flattened into cir- 
cular discs, one inch in diameter, and the centre is pierced with a hole 
for a steel rivet, making an antero-posterior joint. In order to pre- 
vent the dropping of the foot, the front lower edge of the flattened disc 
on the lower end of the upright is ground away for a distance of one- 
quarter of an inch, beginning at the middle of its lower part. This 




a 




== P^^1in 



Fig. 586.— Details of Construction. 



leaves a sharp projecting lip at the middle of its lower surface, which 
strikes against a pin inserted into the other disc forming the joint, and 
checks plantar flexion of the foot, although allowing dorsal flexion. 

The upright is bent in such a way as not to strike the internal mal- 
leolus when the foot is placed in a position of valgus. 

(V) The calf band consists of a leather strap going around the leg, 
which starts from and is buckled to a small steel plate at the top of the 
upright. 

Leather and Straps. — The sole plate is covered by thin calfskin, felt 
being placed between the leather and the side flanges of the foot-piece. 
Strong webbing straps are furnished to secure the foot in the sole plate 
and to press the head of the os calcis, the astragalus, and the external 
malleolus to the inner side. These straps are fastened on the outer 
side to a triangular piece of leather riveted to the sole plate, and extend 



PRACTICAL DETAILS OF APPARATUS. 649 

on the outer side so as to furnish pressure on the outer side of the os 
caleis. The straps pass around the ankle and are secured to catches or 
buckles placed on the lower and broader portion of the upright. 

The front strap passes through a steel guard attached to the upright 
at the level of the ankle, which protects the strap from chafing the up- 
right. 

A strap to keep the heel down is sometimes needed. It is riveted 
to the sole plate, passes on both sides of the ankle, and is secured by a 
buckle in front of the ankle. Felt is needed to prevent the skin from 
being chafed. A strap runs across the front of the foot to keep the 
foot close to the plate. 

28. APPARATUS FOR TALIPES EQUINUS. 

For uncomplicated talipes equinus two types of apparatus are in use. 
This apparatus consists of (a) one or two uprights, (&) a foot-piece, 
and (V) a posterior calf band. 

(a) The uprights are one or two in number. If two are used, one is 
outside and one inside the leg, and these run from the bottom of the ankle- 
joint outside of the boot to a point one inch below the tubercle of the 
tibia, where they are joined by a posterior calf band. They are made 
of cast steel, No. 10 gauge, and should be shaped to follow the outline 
of the leg, clearing the malleolus. At the bottom the upright proper 
ends at the ankle-joint, the part below the ankle-joint being considered 
the foot-piece. The lower end of the upright is flattened into a circu- 
lar disc, five-eighths of an inch in diameter, and its centre is drilled for 
a hole for the connecting spindle of the joint. Both uprights are finished 
in the same way, the level of the joint being just below the prominent 
part of the internal malleolus. If one upright is used, it should be 
made of sheet steel, No. 10 gauge, and ends in a posterior calf band 
fastened around the leg by a strap and buckle. 

(b) The foot-piece consists of a sole plate and two pieces running up 
to join the uprights. The sole plate consists of a piece of sheet steel, 
No. 17 gauge, with a straight posterior edge, which runs far enough 
back to pass between the heel of the boot and the sole of the shoe, 
being covered by the heel of the boot. Its anterior end then runs 
along the under side of the shank of the boot for a distance of one-half 
of an inch, being covered on its anterior part by an extra piece of sole 
leather, tapped on to the bottom of the sole of the boot covering in the 
front of the foot-piece. The steel tongue which runs forward should be 
narrower than the shank of the boot and run well forward to the meta- 
tarso-phalangeal joint. It is riveted to the sole of the shoe through 
holes drilled in it in three or four places. The side arms of the foot- 
piece should be at least one-quarter of an inch wider than the foot 



650 



ORTHOPEDIC SURGERY. 




& 



where they pass up at the edge of the sole. They should be turned 
up at a right angle to join the lower ends of the upright, and should 
be flattened and drilled as described to form a joint with the lower 
ends of the upright. 

Joint. — In order to prevent the plantar flexion of the foot, which is 
the deformity to be corrected in talipes equinus, the joint must be con- 
structed in the same way as in the splint 
for equino-varus to prevent dropping of the 
foot. 

(e) The posterior calf band at the top of 
the upright is made of No. 17 gauge sheet 
steel, riveted to the inner surface of the up- 
right or uprights at the top, and curved to fit 
the calf of the leg. This is padded with felt, 
covered with leather, and provided with a 
strap and buckle to pass round the anterior 
part of the leg. 

The apparatus may be finished by being 
nickel-plated, blued, or japanned. 

Another type of apparatus may be used 
for uncomplicated talipes equinus, which is 
less unsightly, as it goes inside the boot. It 
consists of (a) a foot-piece, (b) two up- 
rights, (V) a posterior calf band, and in con- 
struction it follows the lines indicated in 
speaking of the fixation splint for ankle- 
joint disease, except that it is jointed oppo- 
site the malleolus and that no lacing over the foot is required. It is 
not attached to the boot. 

(a) The foot f plate is covered with a smooth piece of thick leather, 
riveted on, and is worn inside the boot. The joint at the ankle is of 
the same kind as that described in the apparatus just mentioned for 
talipes equinus with a right-angle stop-catch. The apparatus in other 
respects presents no difference. 

Apparatus for Talipes Equinus Complicated with Varus or 

Valgus. 



Fig. 587.— Apparatus for Tali- 
pes Equinus,with Stop Catch. 
On the right of the picture is 
a detail drawing of the stop 
for talipes calcaneus, on the 
left a catch allowing slight 
motion. 



The apparatus for equino-varus has already been described. When 
talipes equinus exists with any degree of valgus, the shoe described in 
speaking of talipes valgus is the most useful, and the only modification 
necessary in it is the addition of a right-angle stop-catch to prevent 
plantar flexion of the foot. This is identical in construction with the 
joint described in speaking of the apparatus for equinus. 



PRACTICAL DETAILS OF APPARATUS. 65 1 

29. APPARATUS FOR TALIPES CALCANEUS. 

For uncomplicated cases of talipes calcaneus the forms of appa- 
ratus described for talipes equinus are to be used, with a simple mod- 
ification'. 1 This modification consists in reversing the stop-joint at 
the ankle, so that it prevents dorsal flexion but allows plantar flexion 
to the foot. This is done by cutting away the posterior half of the 
lower surface of the disc forming the lower end of the upright, and 
putting a pin in the part of the foot-piece at such a place that it will 
strike against the projecting lip left at the anterior half of the lower 
border of the foot-piece. It is only necessary to do this over the outer 
malleolus, and the inner joint may be left free. The construction in 
other respects is the same as that described in speaking of the joint for 
talipes equinus. If talipes calcaneus exists with either varus or valgus, 
the varus or valgus shoe with a steel sole plate should be provided with 
an appropriate stop-joint. 

30. APPARATUS FOR TALIPES VARUS. 

For cases of a severe grade the splint described for the treatment 
of equino-varus is to be used, without the right-angle stop-catch at the 
ankle-joint. 

For cases of lighter grade the reverse of the apparatus described for 
talipes valgus would be of use. In this apparatus the upright and foot- 
piece should run up the inner side of the leg. The joint is opposite the 
inner malleolus, and the T-strap is fastened to the outer border of the 
shank of the boot and passes around the external malleolus. This ap- 
paratus is, of course, much less efficient than the one just described. 

31. APPARATUS FOR TALIPES VALGUS. 

The deformity in talipes valgus is most easily controlled by an ap- 
paratus following the same general lines in its construction as that de- 
scribed for equino-varus, except that, of course, the upright runs on the 
outside of the leg and the pull of the apparatus is reversed. This 
apparatus consists of (a) an upright, (b) a sole plate, and (V) a calf 
band. 

(a) The upright is made of steel similar to that described in speak- 
ing of the shoe of equino-varus, and runs from a point one inch below 
the tubercle of the tibia, where it terminates in a band forming about 
one-third of a circle and curved to fit the outer contour of the leg, 
avoiding the external malleolus. 

(J?) The sole plate consists of a flat plate of No. 16 gauge sheet 

1 See Fig. 587. 



652 



ORTHOPEDIC SURGERY. 



steel, turned up at a right angle along its outer border for a distance 
of three-quarters of an inch to follow the outer border of the foot. 
This turned-up edge should reach from behind the head of the fifth 
metatarsal to a point one-half of an inch in front of the posterior part 
of the os calcis. . It is often necessary to bend it out or cut it away 
over the base of the fifth metatarsal. The length of the bottom 
of the plate is from just behind the cleft between the toes and the ball 





FIG. 588.— Apparatus for Talipes Valgus. 

of the foot to a point one-half of an inch in front of the posterior end 
of the os calcis. Its width is one-quarter to one-half of an inch less 
than the breadth of the sole of the foot. It is generally desirable to 
arch the inner surface of the plate somewhat to follow the curve of the 
arch of the foot. This adds to the efficiency of the apparatus by help- 
ing to antagonize the valgus by preventing dropping of the arch and 
rolling of the foot on to its inner side. 

This plate is connected with the upright by means of a right-angled 
piece of machine steel, No. 10 gauge, three-quarters of an inch wide, 
which runs across its under surface and is riveted to the sole plate. On 
the outer border of the sole plate it turns up at a right angle and runs 
to a point opposite the external malleolus, where its upper end is flat- 
tened into a disc, five-eighths of an inch in diameter, the centre of 
which is drilled by a hole, three-eighths of an inch in diameter, for the 
insertion of a spindle which connects it with the lower end of the up- 



PRACTICAL DETAILS OF APPARATUS. 653 

right. In the case of a pure valgus deformity there is no need of a 
stop-catch at the joint. If the valgus is associated with an equinus de- 
formity a stop-catch is required, of the kind described in speaking of 
the apparatus for equinus. If it is associated with a calcaneus deform- 
ity the reverse stop should be used, which is described in speaking of 
calcaneus. 

(c) The band is provided with a strap and a buckle to encircle the 
leg, and is padded with felt and covered with leather. It is riveted to 
the inner surface of the top of the upright. 

The foot is fastened to the sole plate by means of two or three web- 
bing straps, which are riveted to the inner border of the sole plate, pass 
over the dorsum of the foot and the turned-up outer edge of the plate, 
to fasten into clasps described in the shoe for equino-varus. These are 
fastened on to the outer surface of the turned-up edge of the foot plate. 
One of these straps will be required at the front of the foot and one 
toward the posterior part of the foot plate. 

The essential part of the apparatus is a T-strap, which passes around 
the inner malleolus, holding it outward. This strap, which should be 
made of sole leather, is fastened at its base to the upper surface of the 
inner border of the foot plate directly below the internal malleolus. It 
passes upward and broadens one inch below the malleolus to form two 
straps, which run at right angles to the vertical axis of the leg. The 
height of this strap should be the distance from the foot plate to a point 
one inch or less above the lower border of the internal malleolus. The 
horizontal parts of the T-strap then pass outward at the level of the 
malleolus around the upright and below the malleolus. One strap is 
furnished with a leather buckle, five-eighths of an inch wide, into which 
the other end of the strap fastens. It is desirable that this buckle, when 
fastened in place, should lie against the outer side of the upright, so 
that it does not lie against the soft parts. 

The measurements of the splint are self-evident. A cardboard pat- 
tern of the sole plate should be furnished and the length given from the 
bottom of the sole plate to a point one inch below the tubercle of the 
tibia. The height of the external malleolus from the sole plate is given. 
The posterior band is one-third of the circumference of the calf at that 
level. 

A simpler and lighter apparatus may be used for uncomplicated 
cases of talipes valgus. It consists of (a) an upright, (b) a foot-piece, 
and (c) a calf band. 

(a) The upright extends on the outside of the leg from the external 
malleolus to a point one inch below the tubercle of the tibia. It is 
made of machine steel and is five-eighths of an inch wide. It is fastened 
to the top of the foot-piece at the ankle-joint by means of a free joint 
similar to that described in speaking of the apparatus for knock-knee. 



654 



ORTHOPEDIC SURGERY. 



(h) The foot-piece is similar to that described in the apparatus for 
knock-knee, and is fastened to the bottom of the shoe and runs up on 
the outside of the foot to join the upright at the outer malleolus. 

(c) The calf band is like that described in the other apparatus for 
valgus. The apparatus is entirely outside of the shoe and is put on 
and off with the shoe. The T-strap described in speaking of the other 
apparatus for valgus is fastened to the bottom of the inside of the shank 
of the boot at a point directly below the internal malleolus. It runs up 
and buckles around the upright of the splint in a manner similar to that 
described in speaking of the other apparatus for valgus, except that, of 
course, it is outside of the boot. If any element of equinus or calcaneus 
exists, an appropriate stop-joint is put in at the ankle, as has been de- 
scribed in speaking of these affections. 

32. FLAT-FOOT PLATES. 

The details of the manufacture of flat-foot plates have been so fully 
described in the chapter on flat-foot that they will not be discussed here 
(Chapter XX.). 







FIG. 589. -Flat-foot Plates. 



Fig. 590. — Flat- foot Plate 
Raised in Front to Support 
Anterior Arch. 




FIG. 591.— Flat-foot Plate. Right foot. 



33. TOE-POST. 

In cases of hallux valgus it is frequently desirable to introduce a 
vertical partition in the line of the length of the foot between the first 
and second toes, in order to hold the great toe in a correct position. 
This toe-post, as it is called, may be held in place in one of two ways, 



PRACTICAL DETAILS OF APPARATUS. 



655 



It may be passed up through an inner sole fitting accurately in the 
boot, in which case it may be moved from one pair of boots to another ; 
or it may be passed up through the sole of the boot from the under 
surface, in which case it could not, of course, be changed from boot to 
boot. The description in this connection applies to the case of an adult. 
The toe-post at its posterior border is situated one-quarter of an inch 
from the cleft between the first and second toes. At its anterior border 
it should not reach within one-quarter of an inch of the front end of the 
great toe. In height it should not reach above the top surface of the 
great toe with the foot resting on the ground. It is made of sheet steel 
of the required width and one-sixteenth of an inch in thickness. It is 
cut in a strip three and one-half inches long and of the width indicated. 
This strip is then folded in its middle, as one would double a piece of 
paper by creasing. The thickness of the toe from the top to the bot- 
tom is then measured, and the thickness of the sole is added to this and 
marked on the folded piece of steel. At this point a sharp right-angu- 
lar bend is made on each side, the bent ends of ^ 
the steel forming a continuous straight line, with d y j^7 
which the double upright forms a right angle. 
The ends of the steel are then cut off to the 
desired length. A tracing of the foot is then made 
on a piece of paper and the desired position of the toe- 
post is indicated on the tracing. A vertical slit is 
then made in the boot at this point, and the vertical 
part of the toe-post is passed up through it to protrude 
into the boot. The toe-post is more comfortable if 
covered with a thin piece of leather before being intro- 
duced into the shoe. The ends of the steel which are 
against the bottom of the sole are then fastened in 
place, and an extra tap is put on the bottom of the sole 
to cover in the piece of steel which has been fastened to the bot- 
tom. Inside of the boot a stall is thus provided for the great toe. It 
is, of course, necessary in the use of the toe-post that a stocking should 
be worn with a partition between the first and the second toe. The 
measurement as here given applies to the use of the toe-post when 
permanently fastened to the shoe. When it is to be used in an inner 
sole, the height of the vertical part is the measurement of the 
thickness of the toe. It is then passed through a slit in an inner sole 
and the bottom pieces of the toe-post are fastened to the sole by stitch- 
ing. An inner sole should be made of sole leather with the polished 
side up, cut accurately to fit the sole of the boot. 




FlG. 592. — Toe-post 
Inserted in Sole. 



INDEX. 



Abscess, cold, of joints, 8 

in tuberculous disease of hip, 86, 

treatment, 130 
in tuberculous disease of knee, 153 
in tuberculous disease of spine, 19, 

49 
treatment, 79 

psoas, 39, 80 

retropharyngeal, 41, 80 
Acetabular hip disease, 84 
Achillobursitis, 599 
Achillodynia, 599 
Achondroplasia, 282 
Actinomycosis, 264 

of spine, 264 
Amputation for hip-joint disease, 144 

for knee-joint disease, 169 
Angular curvature of spine, 16; and 

Tuberculous disease of spine 
Ankle, congenital dislocation of, 515 

excision of, 175 

functional affections of, 472 

splint for, 632 

sprains of, 227 

synovitis of, 240 

tenosynovitis of, 241 

tuberculous disease of, 171 
Ankylosis, 266 

and immobilization, 127 

formation of new joints in, 269 

treatment, 268 
Anterior poliomyelitis, 406 

apparatus for, 431, 642, 643 

arthrodesis in, 443 

caliper apparatus for, 642 

deformities in, 413 
treatment, 435 

diagnosis, 421 

differential diagnosis, 424 

dislocations from, 419 

distribution of paralysis, 412 
42 



Anterior poliomyelitis, electrical reactions 
96, in, 421 

epidemic, 407 

etiology, 406 

excision for, 444 
39, hip deformity in, 436 

knock -knee in, 416 

nerve transplantation in, 443 
twisting in, 443 

osteotomy for, 444 

paralysis of leg and thigh muscles, 

43 1, 43 2 

apparatus for, 642, 643 
pathology, 408 
prognosis, 426 

supporting leg-brace for, 643 
symptoms, 410 

talipes calcaneo-valgus in, 417 
see calcaneus in, 418 

equino-varus in, 417 

equinus in, 417 
tendon transplantation in, 439 
treatment, 427 

mechanical, 430 

operative, 438 
Apophysalgie Pottique, 31 
Apparatus, ankle splint, 632 
anterior bow-leg irons, 637 

head support, 613 
antero-posterior bow-leg brace, 637 

support for Pott's disease, 607 
back brace, quadrilateral, 615 

quadrilateral, with head support, 
617 
bandages, celluloid, 605 

plaster -of-Paris, 601 
bed-frame, gas-pipe, 618 
bow-leg irons, 635 

brace with movable shoulder-pieces,639 
caliper, for anterior poliomyelitis, 642 
celluloid bandages, 605 
convalescent hip splint, 623 
657 



658 



INDEX. 



Apparatus, double upright hip splint, 625 
equino-varus splint, 646 
fixation ankle splint, 632 
flat-foot plates, 580, 654 
for anterior poliomyelitis, 642, 643 
for bow-legs, 635, 637 
for equino-varus, 646 
for hallux valgus, 654 
for Pott's disease, 607 
for talipes calcaneus, 651 
for talipes equino-varus, 646 
for talipes equinus, 649 
for talipes equinus complicated with 

varus or valgus, 650 
for talipes valgus, 651 
for talipes varus, 651 
gas-pipe bed-frame, 618 
head support, anterior, 613 

oval ring, 612 
hip splints, 619, 623, 625 
jointed knee splint, 630 
knee splints, 627, 629, 630 
knock-knee brace, 633 
leather splints and jackets, 606 
oval ring head support, 612 
plaster-of-Paris bandages, 601 
practical details of, 601 
quadrilateral back brace, 615 

with head support, 617 
supporting leg brace for anterior poli- 
omyelitis, 643 
tempered steel uprights, 638 
Thomas caliper splint, 629 

collar, 615 

hip splint, 625 

knee splint, 627 
toe-post, 654 
torticollis brace, 641 
traction hip splint, 619 
Aran-Duchenne type of muscular atrophy, 

463 
Arthritis, ankylosing, 206 

chronic rheumatic, 196 ; and see Ar- 
thritis deformans 
Arthritis deformans, 196 
atrophic, 205 
chronic, 109 

rheumatoid, 205 
complications, 201 
diagnosis, 207 
etiology, 201 
fibrinous, 206 



Arthritis deformans, in children, 213 

local treatment, 209 

localization, 202 

mechanical treatment of deformities, 
212 

monarticular, 205 

of hip,' 217 

of knee. 219 

of shoulder, 222 

of spine, 214 

of temporo-maxillary joint, 223 

of wrist, 223 

operative treatment, 212 

pathology, 196 

polyarticular, 205 

symptoms, 202 

treatment, 208 

varieties, 205 
Arthritis, dry, 196; and see Arthritis de 
formans 

fibrosa, 206 

gonorrhceal, 194 

infectious, 193, 206 

of infants, 192 

proliferating, 196; and see Arthritis 
deformans 

rheumatoid, 196; and see Arthritis de- 
formans 
Arthropathy, neural, 259 

neuropathic, 259 

of hip, 260 

of vertebral column, 260 

spinal, 259 

tabetic, 259 
Articular tuberculosis, 1; and see Tuber- 
culosis of joints 
Articuli duplicati, 271; and see Rickets 
Atrophic spinal paralysis, acute, 406 
Atrophy, in tuberculous disease of hip, 93, 
107 

in tuberculous disease of knee, 150 

unilateral, 476 
Attitude in rickets, 276 

in tuberculous disease of hip, 103 

in tuberculous disease of spine, 27 

of rest, 284 

Bandy legs, 296; and see Bow-legs 
Bartlett's machine for reducing congenital 

dislocation of hip, 497 
Bechterew's disease of spine, 214 
Bed-frame, gas-pipe, 618 



INDEX 



659 



Bone, caries of, 1 

changes in, in rickets, 274 
syphilis of, 252 
tuberculosis of, 1 
tumors of, 249 
Bow-legs, 296 

anterior curvature in, 297, 302 
apparatus for, 637 
treatment, 305 
apparatus for, 301, 635, 637 
causation, 297 
diagnosis, 299 
occurrence, 297 
osteoclasis, 302 
osteotomy, 304 
prognosis, 300 
symptoms, 297 
treatment, 300 

expectant, 300 
mechanical, 301 
operative, 302 
Brace with movable shoulder-pieces, 639 
Brain, operation on, in spastic paralysis, 457 
Buckminster Brown's splint for torticollis, 

400, 641 
Bunion, 594 
Bursae of hip, 243 

Bursitis of deep prepatellar bursa, 245 
of hip, 243 
of knee, 244 
of shoulder, 246 
prepatellar, 244 

deep, 245 
post-calcaneal, 599 

Caliper apparatus, 642 

splint, 161, 629 
Caput obstipum, 392; and see Torticollis 
Carcinoma of bone, 250 

of spine, 250 
Caries of bone, 1 

of spine, 16; and see Tuberculous dis- 
ease of spine 
Cartilages, loose, 231 
Casts of foot, to make, 580 
Casts for flat-foot plates, 580 
Celluloid bandages, 605 
Cerebellar type of hereditary ataxia, 465 
Cerebral paralysis, 445; and see Spastic 

paralysis 
Charcot's disease of hip, 260 

joint disease, 259 



Chest, rhachitic, 275 
Chicken-breast, 389 
Children, arthritis deformans in, 213 
Chondrodystrophia foetalis, 282 
Chondroma of bone, 250 
Clawed toes, 598 

Club-foot, 518; and see Talipes equino- 
varus 
acquired, 548 
non-deforming, 576 
paralytic, 548 
Club-hand, 556 
Cold abscess of joints, 8 
Collum distortum, 392; and see Torticollis 
Congenital dislocation of ankle, 515 
of elbow, 515 
of hip, 479 
of knee, 512 
of patella, 514 
of shoulder, 515 
of wrist, 516 
elevation of scapula, 391 
torticollis, 392 
Contracted foot, 576 
Convalescent hip splint, 623 
Coxa valga, 320 
Coxa vara, no, 308 

after-treatment, 320 
diagnosis, 314 
etiology, 308 
osteotomy for, 318 
pathology, 309 
prognosis, 316 
splints, 316, 623, 627 
symptoms, 313 
traumatic, 311 

treatment, 320 
treatment, 316 
Coxalgia, 84; and see Tuberculous disease 

of hip 
Coxitis, 84 ; and see Tuberculous disease of 
hip 
senile, 218 
Craniotabes, 275 
Cubitus valgus, 516 

varus, 516 
Cysts of knee, 240 

Degenerative ataxia, 464; and see 

Hereditary ataxia 
Dental paralysis, 406; and see Anterior 

poliomyelitis 






66o 



INDEX. 



Diffuse muscular lipomatosis, 458; and see 
Pseudo-hypertrophic muscular paralysis 
Dislocation of hip, congenital, 479 
in hip disease, 85 
of patella, habitual, 246 
of semilunar cartilages, 236 
of shoulder, habitual, 248 
Dislocations, congenital, 479 

from infantile paralysis, 419 
Distribution of chronic tuberculous joint 

disease, 11 
Dropsy of joint, 228 

Dry arthritis, 196; and see Arthritis 
deformans 

Echinococcus cysts of spine^jd^ 
Elbow, congenital dislocation of, 515 

excision of, 181 

synovitis of, 243 

tennis, 243 

tuberculous disease of, 179 
Empyema tuberculosum, 7 
Epiphyseal disjunction, 311 
Equino-varus splint, 646 
Erb's type of muscular atrophy, 463 
Essential paralysis of children, 406 
Excision for anterior poliomyelitis, 444 

of ankle, 175 

of elbow, 181 

of hip, 137 

causes of death in, 140 
functional results, 141 
indications for, 142 
mortality of, 141 

of knee, 166 

of shoulder, 178 

of wrist, 182 
Exostoses, 249 

bur sate, 250 

cartilaginous, 250 

of os calcis, 600 

of tarsal bones, 600 

False tumor albus, 254 

Family ataxia, 464; and see Hereditary 

ataxia 
Feet, examination of, 578 
Femur, fracture of neck of, 311 
infraction of neck, of, 311 
sarcoma of, 252 
Fixation treatment of tuberculous disease of 
hip, 116, 124 



Fixation treatment of tuberculous disease 

of knee, 158, 163 
Flat-foot, 559 

causation, 569, 571 

diagnosis, 578 

differential diagnosis, 579 

forcible correction of, 589 

pathology, 561 

plates for, 580, 654 

prognosis, 580 

symptoms, 572 

tender points in, 574 

treatment, 580 

varieties, 569 
Flexed toes, 598 
Floating bodies in joints, 231 
Fcetal rickets, 282 
Foot, anatomy of bones of, 563 

casts of, to make, 580 

in infancy, 560 

normal, 560 

weakened, 566 
Fracture in tuberculous disease of hip, 85 

of neck of femur, 311 
Fractures, improperly united, treatment of, 

3°7 
Friedreich's disease, 464; and see Heredi- 
tary ataxia 
Functional affections of ankle, 472 
of hip, 470 
of joints, 467 

apparatus for, 474, 638 
of knee, 471 
of spine, 469 
Funnel breast, 390 

chest, 390 
Fungus disease, 1 

Gant's osteotomy of hip, 133 

Genu extrorsum, 296; and see Bow-legs 
introrsum, 283; and see Knock-knee 
valgum, 283; and see Knock-knee 
varum, 296; and see Bow-legs 

Genuclast, 165 

Gout, 254 

rheumatic, 196; and see Arthritis 
deformans 

Growing pains, 263 

Hemophilia, joint lesions in, 261 
Hallux rigidus, 597 



INDEX. 



66 1 



Hallux valgus, 593 

toe-post for, 654 
varus, 597 
Hammer toe, 597 
Harrison's sulcus, 276 
Head supports, 612, 613 

in treatment of tuberculous disease of 
spine, 74 
Heberden's nodes, 206 
Heel, painful, 599 

policeman's, 599 
Hemiplegia, spastic, 445; and see Spastic 

paralysis 
Hereditary ataxia, 464 

cerebellar type, 465 
ataxic paraplegia, 464 
Hey's internal derangement of knee, 236 

treatment, 239 
Hip, arthritis deformans of, 217 
arthropathy of, 260 
bursitis of, 243 
Charcot's disease of, 260 
Hip, congenital dislocation of, no, 479 
accidents in treatment of, 501 
after-treatment, 501 
diagnosis, 483 
differential diagnosis, 485 
etiology, 479 
frequency of, 479 
osteotomy in, 507 
pathology, 481 
prognosis, 487 

after-treatment, 508 
reduction by forcible manipula- 
tion, 494 
by open incision, 489 
with aid of mechanical force, 

497 
relapses in, 504 
symptoms, 483 
tenotomy in, 499 
treatment, 488 

accidents in, 501 
of older adult cases, 511 
results of, 504 
summary, 511 
varieties, 482 
Hip disease, 84; and see Tuberculous dis- 
ease of hip 
dislocation of, congenital, 479 

paralytic, 419 
excision of, 137 



Hip, functional affection of, 470 

inflammation, acute infectious, of, 109 

malignant disease of, 252 

osteomyelitis of, 109, 191 

ostitis, chronic articular, of, 84; and 
see Tuberculous disease of hip 

sarcoma of, in 

sprains of, 226 

synovitis of, 108, 228 

tuberculous disease of, 84 
Hip-joint disease, 84; and see Tuberculous 

disease of hip 
Hip-splint, convalescent, 623 

double upright, 625 

Thomas, 625 

traction, 619 
Hollow foot, 554; and see Talipes cavus 
Horse heel, 548; and see Talipes equinus 
Housemaid's knee, 244 
Hydrarthros, 228 
Hydrarthrosis, 228 
Hydrops articulorum chronicus, 228 
articulorum tuberculosus, 7 

intermittent, 228 
Hypersesthetic spine, 51 
Hypertrophy of synovial villi, 230 

unilateral, 476 
Hysterical ankle, 472 

hip, 470 

joints, 467 

knee, 471 

spine, 51, 469 

Immobilization and ankylosis, 127 
Infantile paralysis, 406; and see Anterior 

poliomyelitis 
Infants, arthritis of, 192 
Intermittent hydrops, 228 

synovitis, 228 
Internal derangement of knee. 236 
In-toe, 597 
Ischias scoliotica, 342 

Jaw, arthritis of, 223 
Joint affections in gout, 254 
in haemophilia, 261 
in scurvy, 263 
in syphilis, 252 
disease, Charcot's, 259 
mice, 231 
Joints, cold abscess of, 8 

functional affections of, 467 



662 



INDEX. 



Joints, hysterical, 467 

inflammation of, 193 

loose bodies in, 231 

nodosity of, 196; and see Arthritis de- 
formans 

tuberculous disease of, 1 
Jury-mast, 59, 67 

Knee, arthritis deformans of, 219 

bursitis of, 244 

congenital dislocation of, 512 

cysts of, 240 

dislocation of semilunar cartilages, 
236 

forcible flexion of, 162 

functional affection of, 471 

housemaid's, 244 

hysterical, 471 

internal derangement, 236 

lipoma of, 235 

loose bodies in, 231 

pain in, in hip disease, no 

purulent or fungous synovitis of, 147; 
and see Tuberculous disease of knee 

scrofulous disease of, 147; and see Tu- 
berculous disease of knee 

secondary disturbance of, 240 

sprains of, 226 

synovitis of, 147, 229 

trigger, 240 

tuberculous disease of, 147 

tumor albus, 147; and see Tuber- 
culous disease of knee 
Knees, loose, 287 
Knee splint, jointed, 630 

Thomas, 627 
Knock -knee, 283 

brace for, 292, 633 

diagnosis, 288 

etiology, 283 

gait in, 287 

Macewen's osteotomy for, 293 

manipulation, in treatment, 290 

mechanical production of, 284 

occurrence, 283 

osteoclasis for, 295 
results of, 305 

osteotomy for, 292 
results of, 305 

paralytic, 289 

prognosis, 289 

symptoms 286 



Knock-knee, traumatic, 289 
treatment, 289 

ambulatory, 292 
expectant, 289 
mechanical, 291 
operative, 292 
Kyphosis, 16; and see Tuberculous disease 
of spine; also 376, and see Round 
shoulders 
apparatus for, 382, 638, 639 
static, from occupation, 383 

Laminectomy, 82 

Landouzy-Dejerine type of muscular atro 

phy, 463 
Lateral curvature of spine, 322 

cervical, 335 

curves in, 336 

relative frequency of, 337 

deformity in, 333 

diagnosis, 342 

displacement of abdominal viscera in, 

329 
distortion of pelvis in, 328 
dorsal, 335 
etiology, 330 
examination, 342 
exercises in, 357, 361 
frequency of, 322 
in ischias scoliotica, 342 
jackets for, 365 
limp in, 336 
lumbar, 335 

methods of recording, 345 
pain in, 332 
paralytic, 339 
pathology, 323 
plaster jacket for, 365 
prevention of, 350 
prognosis, 348 
rhachitic, 338 
symptoms, 331 
tracings of, 346 
treatment, 355 

corrective measures, 360 

operative, 373 

postural, 355 
varieties of, 338 
Wolff's law, 325 
Lateral deviation of spine in Pott's disease, 

3° 
Leather splints and jackets, 606 



INDEX. 



663 



Lipoma arborescens, 7, 235 

of knee. 235 

solitarium, 235 
Lipomatous muscular atrophy, 458; and 

see Pseudo - hypertrophic muscular 

paralysis 
Little's disease, 445; and see Spastic 

paralysis 
Loose bodies in joints, 231 

knees, 287 
Lordosis, 384 

Lorenz method of reducing congenital dis- 
location of hip, 494 
Lumbar abscess in Pott's disease, 41 

Pott's disease, 109 
diagnosis, 47 
operations for, 79 

Macewen's osteotomy for knock-knee, 293 
Mahdelung's deformity of wrist, 516 
Malignant disease of hip, 252 

of spine, 51, 250 
Malpositions of limb, in tuberculous disease 
of hip, 94 
in tuberculous disease of knee, 152 
Malum coxae senile, 218 
Malum senile, 196; and see Arthritis de- 
formans 
Malum Pottii, 16; and see Tuberculous dis- 
ease of spine 
Metatarsalgia, 591 

anterior, 591 
Morbus anglicus, 271; and see Rickets 
Morbus coxae, 84; and see Tuberculous dis- 
ease of hip 
senilis, 109 
coxarius, 84; and see Tuberculous dis- 
ease of hip 
Morton's disease, 591 
Movable bodies in joints, 231 
Muscular pseudo-hypertrophy, 458; and see 
Pseudo-hypertrophic muscular paralysis 
Myelitis of the anterior horns, 406 
Myogenic paralysis, 406; and see Anterior 

poliomyelitis 
Myopachynsis lipomatosa, 458; and see 
Pseudo-hypertrophic muscular paralysis 
Myositis ossificans, 265 

Nervous system, pathological conditions 

of, 259 
Neural arthropathy, 259 



Neuromimesis, see Functional affections of 

joints, 467 
Neuromimetic spine, 51 
Neuropathic arthropathy, 259 

curvature of spinal column, 214 
New joints, formation of, in ankylosis, 

269 
Night cries in hip disease, 92, 107 

treatment of, 131 
Nodes, Heberden's, 206 
Nodosity of joints, 196; and see Arthritis 

deformans 
Nodular rheumatism, 196; and see Arthritis 

deformans 
Non-deforming club-foot, 576 

Obstetrical paralysis, 465 
Orthopedic surgery, scope of, 1 
Os calcis, exostosis of, 600 
Osteoarthritis, 196; and see Arthritis de- 
formans of spine, 214 
Osteoarthropathy of hereditary syphilis, 
254 

secondary hypertrophic, 263 
Osteochondritis of Parrot, 253 
Osteoclasis, for knock-knee, 295 

for bow-legs, 302 
Osteoclast, Rizzoli's, 302 
Osteomalacia, 280 

chronica deformans hypertrophica, 255 
Osteomyelitis, infectious, 186 

diagnosis, 188 

differential diagnosis, 188 

etiology, 186 

pathology, 187 

prognosis, 189 

symptoms, 188 

treatment, 189 
Osteomyelitis of hip, 109, 191 

of spine, 190 
Osteotomy for anterior poliomyelitis, 444 

for bow-legs, 304 

for congenital dislocation of hip, 507 

for coxa vara, 318 

for deformity at knee, 168 

for knock-knee, 292 

for tuberculous disease of hip, 133 

for tuberculous disease of knee, 168 
Ostitis deformans, 255 
Ostitis of hip, chronic articular, 84; and see 

Tuberculous disease of hip 
Out-knee, 296; and see Bow-legs 



664 



INDEX. 



Paget's disease, 255 

Painful heel, 599 

Palsy, teething, 406; and see Anterior 

poliomyelitis 
Paralysis, acute atrophic spinal, 406 

cerebral, 445 ; and see Spastic paralysis 

dental, 406; and see Anterior poli- 
omyelitis 

essential, of children, 406 

infantile, 406; and see Anterior polio- 
myelitis 

in Pott's disease, 20. 37, 50, 81 

in rickets, 274 

myogenic, 406; and see Anterior polio- 
myelitis 

obstetrical, 465 

pseudo-hypertrophic muscular, 458 

regressive, 406; and see Anterior polio- 
myelitis 

spastic, 445 
Parrot's disease, 253 
Patella, congenital alsence of, 514 
dislocation of, 514 

dislocation of, habitual, 246 

slipping, 246 
Pectus carinatum, 389 

excavatum, 390 

gallinatum, 389 
Periarthritis of shoulder, 242 
Periarticular disease, no 
Perineal band, 120 
Pes arcuatus, 554; and see Talipes cavus 

calcaneus, 551; and see Talipes cal- 
caneus 

cavus, 554; and see Talipes cavus 

contortus, 518; and see Talipes equino- 
varus 

equinus, 548; and see Talipes equinus 

excavatus, 554; and see Talipes cavus 

planus, 572; and see Flat-foot 

pronatus, 572; and see Flat-foot 
Phelps' operation in club-foot, 537 
Pigeon breast, 389 

toe, 597 
Plantar fascia, division of, 532 
Plaster casts of foot, to make, 580 

jackets, application of, 58, 60, 63, 65, 
68 
removable, 67 
Plaster-of-Paris bandages, 601 

splint, 125 
Podagra, 255 



Policeman's heel, 599 
Poliomyelitis, anterior, 406 
Porencephalus, 452 

Pott's disease, 16; and see Tuberculous 
disease of spine 

support for, 607 
Prepatellar bursitis, 244 
Progressive muscular atrophy, 462 

types of, 463 
Proliferating arthritis, 196; and see Arthritis 

deformans 
Protection splint in hip disease, 127 
Pseudoarthrosis, 192 

Pseudo-hypertrophic muscular paralysis, 
458 

attitude in, 459 

diagnosis, 461 

etiology, 458 

mental defect in, 459 

pathology, 458 

prognosis, 462 

symptoms, 458 

talipes equinus in, 460 

treatment, 462 
Psoas abscess, 39 

treatment, 80 

Quadrilateral back brace, 615 
with head support, 617 

Railway spine, 51 

Reel foot, 518; and see Talipes equino- 

varus 
Regressive paralysis, 406; and see Anterior 

poliomyelitis 
Repair of tendons, 533 
Retropharyngeal abscess, 41, 80 
Rhachitic curves in upper extremity, 307 
Rhachitis, 271; and see Rickets 
Rheumatic arthritis, chronic, 196; and see 
Arthritis deformans 
gout, 196; and see Arthritis deformans 
Rheumatism, chronic articular, 196; and 
see Arthritis deformans 
gonorhceal, 194 

nodular, 196; and see Arthritis de- 
formans 
Rheumatoid arthritis, 196; and see Arthritis 

deformans 
Rickets, 271 

adolescent, 273 
attitude in, 276 



INDEX. 



665 



Rickets, bone changes in, 274 

causation, 273 

chest in, 275 

congenital, 283 

craniotabes 275 

diagnosis, 279 

differential diagnosis, 279 

foetal, 282 

Harrison's sulcus, 276 

late, 273 

latent, 283 

occurrence, 272 

paralysis of, 274 

pathology, 271 

pelvic deformity in, 277 

prognosis, 279 

rosary, 275 

spine in, 276 

symptoms, 274 

treatment, 280 
Rigidity of spine, 214 
Rizzoli's osteoclast, 302 
Rosary in rickets, 275 
Rotary lateral curvature, 322; and see 

Lateral curvature of spine 
Round shoulders, 377 

apparatus for, 382, 638, 639 

treatment, 379 
Rupture of spinal ligaments, 226 



Sacroiliac disease, 183 
Sacro-coxalgia, 183 
Sacro-coxitis, 183 
Sarcoma of bone, 250 

of femur, 252 

of hip, in 

of spine, 250 
Scapula, congenital elevation of, 391 
School seats, 351 

Scoliosis, 322, 333; and see Lateral curva- 
ture of spine 

ischiatica, 342 

neuromuscularis, 342 

neuropathica, 342 
Scrofulous disease, 1 

of knee, 147; and see Tuberculous dis- 
ease of knee 
Scurvy, joint affections in, 263 
Semilunar cartilages, dislocation of, 236 

treatment, 239 
Senile coxitis, 218 



Shortening in tuberculous disease of hip, 
97, 103, 136 

in tuberculous disease of knee, 150 
Shoulder, arthritis deformans of, 222 

bursitis of, 246 

congenital dislocation of, 515 

excision of, 178 

habitual dislocation of, 248 

obstetrical paralysis of, 465 

periarthritis of, 242 

synovitis of, 241 

tenosynovitis of, 242 

tuberculous disease of, 176 
Spastic hemiplegia, 445; and see Spastic 

paralysis 
Spastic paralysis, 445 

after-treatment, 456 

atrophy in, 447 

condition of muscles in, 448 

contractures in, 447 

diagnosis, 453 

etiology, 451 

mental defects in, 447 

operations upon brain for, 457 

pathology, 451 

prognosis, 453 

symptoms, 445 

tendon transferrence for, 457 

treatment, 454 

operative, 455 
Spinal arthropathy, 259, 260 

column, neuropathic curvature of, 214 

curvature, 16; and see Tuberculous 
disease of spine 

ligaments, rupture of, 226 

paralysis, acute atrophic, 406 
Spine, actinomycosis of, 264 

angular curvature of, 16; and see Tu- 
berculous disease of spine 

ankylosing inflammation of, 214; and 
see Spondylitis deformans 

arthritis deformans of, 214 

Becbterew's disease of, 214 

carcinoma of, 25c 

caries of, 16; and see Tuberculous dis- 
ease of spine 

echinococcus cysts of, 265 

functional affection of, 469 

hypera?sthetic, 51 

hysterica], 51, 469 

irritable, 469 

lateral curvature of, 322 



666 



INDEX. 



Spine, malignant disease of, 51, 250 

neuromimetic, 51 

osteoarthritis of, 214 

osteomyelitis of, 190 

railway, 51 

rigidity of, 214 

sarcoma of, 250 

spondylitis deformans of, 214 

sprains of, 225, 470 

syphilis of, 254 

tuberculosis of, 16 

typhoid, 191 

variations in length of, 375 
Splay-foot, 572; and see Flat-foot 
Spondylitis, 16; and see Tuberculous dis- 
ease of spine 

deformans, 214 

traumatic, 226 
Spondylolisthesis, 385 
Sprains, 224 

of ankle, 227 

of back, 50 

of hip, 226, 228 

of knee, 226 

of spine, 225, 470 *- 

of wrist, 227 
Sprengel's deformity, 391 
Spurious valgus, 572; and see Flat-foot 
Strumous disease, 1 
Subluxation of wrist, spontaneous, 516 
Symphysis pubis, relaxation of, 249 
Synovial villi, hypertrophy of, 230 
Synovitis, arborescent tuberculous, 7 

chronic, 228 

intermittent, 228 
serous, 228 

gonorrheal, 194 

infectious, 193 

of ankle, 240 

of elbow, 243 

of hip, 108, 228 

of knee, 229 

purulent or fungous, 147; and see 
Tuberculous disease of knee 

of shoulder, 241 

of tendo Achillis, 600 

of wrist, 243 

purulent or fungous, of knee, 147; and 
see Tuberculous disease of knee 
Syphilis and rickets, 274 

of bone, 252 

of spine, 254 



Tabetic arthropathy, 259 
Tables of height and weight, 349 
Talipes, 518 

calcaneus, 551 

apparatus for, 651 
cavus, 554 
equino-varus, 518 
acquired, 548 
apparatus for, 529, 646 
diagnosis, 523 
etiology, 522 

forcible manipulation, 537 
frequency, 518 
manual manipulation, 526 
mechanical correction, 526 

summary of, 537 
operative treatment, 530, 537 
osteotomy, 540 
pathology, 519 
Phelps' operation, 537 
plantar fascia, division of, 532 
plaster-of-Paris bandages, 527 
prognosis, 524 
relapses, 545 
splint for, 646 
symptoms, 522 
tenotomy, 530 
treatment, 525 

generalization, 547 
equinus, 548 

apparatus for, 551, 649, 650 
valgus, 552 

apparatus for, 651 
varus, 554 

apparatus for, 651 
Tarsal bones, exostoses of, 600 
Teething palsy, 406; and see Anterior 

poliomyelitis 
Tempered steel uprights, 638 
Temporo-maxillary joint, arthritis deform- 
ans of, 223 
Tendo Achillis, synovitis of, 600 

- tenotomy of, 530 
Tendon transference in spastic paralysis, 

457 
transplantation in anterior poliomye- 
litis, 439 
Tendons, divided, repair of, 533 
Tennis elbow, 243 
Tenosynovitis of ankle, 241 
of shoulder, 242 
of wrist, 243 



INDEX. 



667 



Tenotomy in congenital dislocation of hip, 

499 

in spastic paralysis, 455 

of tendo Achillis, 530 
Thomas caliper splint, 629 

collar, 615 

hip splint, 126, 625 

knee -splint, 159, 627 
Thorax, deformities of, 389, 390 
Tibia, lesions of tubercle of, 226 
Toe-post, 654 
Toes, contraction of, 598 
Tophi, 255 
Torticollis, 392 

acquired, 393 

apparatus for, 400, 641 

brace, 641 

Buckminster Brown's splint, 400, 641 

congenital, 392 

diagnosis, 397 

etiology, 392 

pathology, 394 

physiological, 393 

posterior, 398 

treatment, 403 

prognosis, 398 

spasmodic, 394 

treatment, 403 

symptoms, 395 

treatment, 399 

operative, 400 
Traction hip splint, 619 

in hip disease, 116, 120, 124, 131 

in knee-joint disease, 162 
Traumatic coxa vara, 311 

spondylitis, 226 
Trigger knee, 240 

Tuberculin, as a diagnostic method in tu- 
berculosis of joints, 12 
Tuberculosis, articular 1 ; and see Tu- 
berculous disease of joints 

of bone, 1 

of vertebrae, 16; and see Tuberculous 
disease of spine 
Tuberculous disease of ankle, 171 

diagnosis, 173 

excision, 175 

fixation brace, 173, 632 

mechanical treatment, 173 

operative treatment, 175 

prognosis, 173 

symptoms, 171 



Tuberculous disease of elbow, 179 
excision of, 181 
symptoms, 179 
treatment, 180 
Tuberculous disease of hip, 84 
abduction in, 104 
abscess in, 86, 96, 115 

treatment of, 130 
acetabular, 84 
adduction in, 104 
after-treatment, 136 
ambulatory treatment in, 124 
amputation for, 144 
ankylosis in, 127 
atrophy in, 93, 107, 115 
attitudes in, 94, 103 
bed -frame for, 117, 618 
cause of death, in 
clinical history, 88 
complications, treatment of, 13c 
convalescence, treatment during 12 j 
convalescent splint, 623 
course of disease, 89 
crutches in, 123 
curetting a*hd drainage in, 137 
deformity in, 114 

treatment of, 131 
diagnosis, 99 
differential diagnosis, 108 
dislocation in, 85 
distortion, 114 
double, 99, 136 
duration of treatment, 113 
early symptoms, 88 
examination in, 100 
excision, 137 

results of, 140 
fixation, 116 

splints, 124 
flexion, 106 
fracture in, 85 
functional results, 112 
general condition in, 98 
hysterical, no 
immobilization in, 127 
lameness in, 90, 102 
leather splints, 124, 606 
limping in, 88, 102 
malposition of limb in, 94 
measurements in, 104 
modified traction splints, 124 
mortalitv, in 



668 



INDEX. 



Tuberculous disease of hip, muscular fixa 
tion in, 92, 100 

spasm in, 92, 100 
night-cries in, 92, 107 

treatment, 131 
operative treatment,' 137 
osteotomy, 133 
pain in, 89, 90, 107, no 
pathology, 84 
periarticular symptoms, 95 
perineal bands, 120 
plaster-of-Paris splint in, 125 
plaster bandage, 124, 601 
prognosis, in 

protection splints in, 127, 623 
recovery, 112 
relapses, 129 
remissions in, 98 

separation of ephiphyses in, 85, in 
shortening in, 97, 103, 114, 136 
summary of treatment, 145 
swelling in, 107 
symptoms, 88 
temperature, 99 

Thomas splint in, 124, 126, 625 
traction, 116 

splint in, 119, 123, 124, 619 

straps in, 120 
treatment, 115 

of complications, 130 

operative, 137 

principles of, by fixation and trac 
tion, 116 

summary of, 145 

of mechanical, 130 

termination, 129 
Tuberculous disease of joints, 1 
diagnosis, 12 
etiology, 9 
distribution of, 11 
origin, 4 
prognosis, 12 
pathology, 1 
process of repair, 6 
terminations, 4 
treatment, 13 

general, 13 

local, 14 
Tuberculous disease of knee, 147 
abscess in, 153 

treatment, 166 
amputation for, 169 



Tuberculous disease of knee, ankylosis, 
168 
arthrectomy, 168 
atrophy in, 150 
caliper splint, 161, 629 
clinical history, 148 
complications, treatment of, 161 
deformity, 152 

treatment, 161 
diagnosis, 154 
differential diagnosis, 154 
dislocation in, 152 
erasion, 168 
excision, 166 
fixation, 158, 163 

bandages in, 163 
forcible reduction in, 163 
genuclast, 165 
lameness, 152 
muscular fixation, 152 
osteotomy in, 168 
pain, 151 
pathology, 147 
prognosis, 156 
protective splint, 159 
rotation of tibia, 153 
shortening in, 150 
swelling in, 149 
symptoms, 149 
Thomas splint, 159, 627 
traction in, 162 

splint, 630 
treatment, 157 
Tuberculous disease of sacro-iliac joint, 183 

of shoulder, 176 
Tuberculous disease of spine, 16 
abscess in, 19, 39 

diagnosis of, 49 

treatment of, 79 
ambulatory treatment, 57 
antero-posterior support, 68, 607 
apparatus for correction, 69, 607 
attitude in, 27, 44 
bed-frame for, 54, 618 
Calot's reduction, 77 
cardiac and vascular changes in, 22 
celluloid bandages, 605 
cervical, 45 

abscess, 41 

operations for,- 78 
chest in, 36 
collars, 75, 615 



INDEX. 



669 



Tuberculous disease of spine, complica- 
tions, 37 
corsets, 605, 606 
deformity, 22, 33, 36 

correction of, 77 

tracings of, 34, 37, 70, 71 
diagnosis, 43 

of -abscess in, 49 

of paralysis in, 50 
dorsal, 47 

abscess, 41 
etiology, 23, 25 
examination, 43 
eye symptoms, 32 
forcible correction, 77 
gait in, 44 

general condition, 37 
head supports in, 74, 612, 613, 615 

traction in, 56 
history, 16 

jury-masts for, 59, 67 
laminectomy in, 82 
lateral deviation in, 30 
leather jackets, 606 
localization, 24 
lumbar, 47, 109 

abscess in, 41 

diagnosis of, 47 
mortality, 53 
muscular stiffness in, 44 
occurrence, 23 
pain in, 31 
paper jackets, 60 
paralysis in, 37 

diagnosis of, 50 

pathology, 20 

treatment, 81 
pathology, 16 
plaster jackets, 57, 601 
prognosis, 52 
psoas abscess, 39 

treatment, 80 
psoas contraction, 30, 48 

treatment, 80 
recumbency-treatment, 54 
removable jackets, 67 
retardation of growth in, 35 
retropharyngeal abscess, 41, 80 



Tuberculous disease of spine, spontaneous 
cure in, 34 
suspension in, 58 
summary of treatment, 82 
symptoms, 25 
temperature in, 36 
Thomas collar, 614 
tracings of deformity, 34, 37, 70, 71 
traction in, 56 
treatment, 54 

ambulatory, 57 
apparatus for, 69, 607 
by collars, 75 
by forcible correction, 77 
by head supports, 74 
by plaster jackets, 57, 601 
by recumbency, 54 
by steel appliances, 69 
operative measures, 78 
selection of method, 76 
summary of, 82 
Tuberculous disease of wrist, 182 
Tuberculous nodules, solitary, 7 
Tumor albus, 147; and see Tuberculous dis- 
ease of knee 
false, 254 
Tumors of bone, 249 
Typhoid spine, 191 

Unilateral atrophy and hypertrophy, 476 

Vertebrae, tuberculosis of, 16; and see 
Tuberculous disease of spine 



White swelling, 147; and see Tuberculous 

disease of knee 
Wolff's law, 325 
Wrist, arthritis deformans of, 223 

congenital dislocation of, 516 

spontaneous subluxation of, 516 

excision of, 182 

Mahdelung's deformity of, 516 

sprains of, 227 

synovitis of, 243 

tenosynovitis of, 243 

tuberculous disease of, 1S2 
Wry -neck, 392; and see Torticollis 



JUN 19 1905 



